TRANSFORMING THE DELIVERY OF INJECTABLE CONTRACEPTIVES IN MOZAMBIQUE Creating a Cost Recoverable Model for Community-Based Distribution of DMPA-SC FINAL REPORT: September 2016 to June 2019
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CO N T EN T EXECUTIVE SUMMARY
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VISION
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PROJECT OVERVIEW
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THE PROJECT MODEL
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LESSONS LEARNED
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KEY PROGRAM INDICATORS
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ABBREVIATIONS AND ACRONYMS CBD
Community-Based Distribution
CwS
Mobile application, Connecting with Sara
CHP
Community health promoters (recruited and trained by PSI)
DMPA-SC
Injectable contraceptive with a subcutaneous administration
(brand name Sayana® Press)
FP
Family Planning
Marieta
Represents an adult Mozambican woman
Movercado Technology platform that the project used in the first year
EXECUTIVE SUMMARY
NGO
Non-governmental organization
OC
Oral Contraceptive
In September 2016, the Community-Based
away from family planning. Only 12% of women of
SP
Sayana® Press, contraceptive injection
Distribution Project began creating a cost recoverable
reproductive age (7% in rural areas) are currently
Tem+
Network of family planning clinics from PSI Mozambique
model for community-based distribution and
using a method of modern contraception.1 Among
administration of Sayana® Press, with the ultimate
married women, 29% have an unmet need for
goal of transforming the delivery of injectable
family planning, meaning they want to stop or delay childbearing but are not using any method
contraceptives in Mozambique. This project was
of contraception.2 A key barrier to use of family
viewed as a first step in getting the government and
planning is an absence of services: 77% of users
clients comfortable with the ultimate goal of self-
currently receive their contraception through the
administration of Sayana® Press, as it is approved
public sector, which is characterized by insufficient
for use in other countries in the region.
reach, overworked nurses who often deliver poor-
In Mozambique, access to high-quality, affordable
quality family planning counseling, long wait times,
family planning products, services, counseling, and
and unreliable supplies of contraceptive products.
information continues to be very limited. Alarmingly,
Even though public clinics are close to free, the
the number of women using contraception drastically
cost of transportation is high because they are often
fell in the last decade as donor priorities shifted
located far from rural areas.3
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Ministério da Saúde (MISAU - MoH), Instituto Nacional de Estatística/National Statistics Institute (INE) and ICF International (ICFI). Moçambique Inquérito Demográfico e de Saúde 2011. Calverton, Maryland, USA: MISAU, INE e ICFI DHS 2011 PSI. Mini-focus groups in Maputo (Feb 2012); ethnographic research in Maputo and Nampula (AV / June 2012)
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With these challenges in mind, the activities for
3. A mobile technology platform, first Movercado
the project were designed using the following three
and later PSI’s Connecting with Sara (CwS),
innovations:
was custom built to link community health promoters and clients. Data collected by the
1. Distribution and administration of a three-
community health promoter through the mobile
month, subcutaneous administration, injectable
platform helped to schedule follow-up visits,
contraceptive, DMPA-SC (Sayana® Press), by
track productivity of community health promoters
community health promoters in the private and
and measure client satisfaction with the service.
NGO sector. This required Ministry of Health
The overall goal of the project was to demonstrate
approval for an advocacy phase of the project to
that these innovations could increase uptake of
train community health promoters to administer
contraceptive methods in peri-urban and rural areas
the injections.
of Mozambique.
2. A cost recovery model whereby the community health promoter would charge clients a subsidized
This project built upon the motivation of
fee for the product and home delivery.
entrepreneurship to connect community health
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promoters to women and girls in their communities in order to extend family planning commodities beyond the reach of public clinics. As DMPA-SC is still a new reproductive health commodity in developing markets, each country that launches it through community-based distribution adds to the evidence base to support the feasibility of cost recovery and potential for scale-up.
Key learnings included: » Marieta is keen on Community-Based Distribution (CBD). Through conversations with clients, PSI found that many embraced the advantages of CBD and found the services accessible and private, with friendly providers. Clients were willing to pay for the method in order to benefit from these services.
Throughout the project, the team had the opportunity to learn and iterate when the planned activities did not result in initial success. Iteration was required on all three innovations of the project: where Marieta (the client) received services, how services were priced, and what technology platform provided the necessary functionality for the project.
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» Marieta prefers to seek out community health promoters (CHPs): Based on research initiated during the project, it became apparent that Marieta preferred to visit the CHP when she needed a service or a product refill rather than having the CHP travel to her. As a result, CHPs
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In Mozambique, access to high-quality, affordable family planning products, services, counseling, and information continues to be very limited set up convenient hours to be available when
» Technology is key. One of the biggest changes in
Marieta could drop by to get the services she
the project was changing the digital platform to
needed. This ultimately became known as the
a more robust application. This change provided
“Manjacaze model” of distribution, named for
the team with greater visibility and gave the
one of the villages in which the project was
CHPs a tool to effectively manage their services.
conducted. CHPs were provided with signs to put
Looking forward, the approaches and tools from
outside their homes, letting Marieta know that
the project will be adapted to inform targeted,
they were open for business.
urban fee-based distribution for the PSI network.
» Recruiting a CBD community health promoter
The CwS app, built specifically for this project, is
is not the same as recruiting a sexual and
currently being used in other PSI programs. CwS
reproductive health CHP. For us to be able to
provides a better way to follow up with users,
build a cost recoverable model, the CHPs needed
which helps to increase continuation rates and
to have an entrepreneurial profile. They needed to understand the business model and be proactive
provides a rich set of data for programmatic activities.
to earn a higher salary. CHPs needed more than
PSI Mozambique is the in-country DMPA-SC focal
just communication skills. They needed capacity
partner for the DMPA-SC Access Collaborative,
to manage their portfolio of family planning users
advising the government on the acceleration of DMPA-
to ensure their clients received the CBD service.
SC. In 2020, 90% of the injectables purchased by the
» Partnership can be built between the private
public sector for Mozambique will be sub-cutaneous.
and public sector. When the last model was
Additionally, with funding from the Children’s
implemented, it piqued the interest of the local
Investment Fund Foundation, PSI supported the
health unit to use the CBD service to decrease
Ministry of Health in the development of a National
the burden on family planning services in the
Roll Out Plan for DMPA-SC, which is now under
local health facility. Although we did not have
review by the Technical Working Group for Family
enough time to engage in a long-term testing
Planning. This defines the activities for roll out in the
phase, we were able to see the partnership take
public sector and outlines the potential pathway for
shape to make a case for future opportunities.
client self-administration and private sector sales.
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PROJECT OVERVIEW PSI Mozambique began this project in September
CHPs. Likewise, CHPs working on demand creation
2016, with funding from Maverick Collective member
within communities could refer women and girls
Stasia Obremskey. The goal of this project was to
interested in other family planning methods to the
develop a cost recoverable model to improve access
Tem+ clinics for further counseling and services
to modern contraceptive methods in peri-urban and
from clinic nurses.
rural areas through a community-based distribution
The project intended to work in the six provinces
(CBD) approach, including administration of the
where the Tem+ clinics are operating, but due to
injectable contraceptive, DMPA-SC, among women of reproductive age and adolescent girls.
set-backs in the approval process for distribution
This project worked in partnership with PSI
only able to operate in four provinces: Maputo,
of contraceptives at the community level, PSI was
Mozambique’s Tem+ private clinics, a network
Gaza, Zambezia and Nampula. PSI did not receive
of private clinics, nurses and community health
approval to work in Sofala and Inhambane provinces
promoters (CHPs) that offer family planning
VISION
because of a pilot introduction of DMPA-SC through
counseling and products. PSI-trained nurses
Government Community Assistants.
worked with CHPs to ensure that women and girls PSI's vision is to be at the forefront of market shaping
through private sector channels via a fee-based
who received DMPA-SC or oral contraceptive pills
Through a fee-based system of CBD, the project
and service delivery efforts to expand our clients’ (we
system incorporating mobile technology. The majority
(OC) at the Tem+ clinics were able to receive re-
leveraged entrepreneurship among community
call her Marieta) options for modern contraception
of DMPA-SC programming by other implementers is
administration of their chosen method in their
health promoters and used technology to bring
where, when and how she wants it. By introducing
currently public-sector focused.
neighborhood by paying a small service fee to the
access to modern contraceptives closer to Marieta.
new products to market, like the injectable
PSI is promoting this project globally, in partnership
contraceptive DMPA-SC (also known as Sayana® Press) and bringing contraceptive choice closer to
and is contributing to the global evidence base
home through community-based distribution, we’re
for DMPA-SC community-based distribution
making contraception easier for Marieta to access.
(CBD). Using lessons learned from the project, we
While approximately ten PSI country offices
intend to replicate it, or some elements, in other
are supporting various elements of DMPA-SC
countries and regions such as Angola, Malawi
introduction and roll out, the Maverick Collective
and Ghana. The impact of this work will therefore
project in Mozambique is the first in which PSI
extend beyond Mozambique and provide some
supported the administration of DMPA-SC to clients.
of the first homegrown challenges, lessons and
Globally, this project is unique as it is implemented
successes in introducing and scaling up DMPA-SC.
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The Project Was Based on Three Proposed Innovations
with Maverick Collective member Stasia Obremskey,
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CBD of DMPA-SC by CHPs
Cost Recoverable Model
Technology As A Tool
Explore ways in which CHPs can play a greater role in providing family planning services in the community with an easy-to-use injectable contraceptive, DMPA - SC.
Develop an incentive scheme for the CHPs to leverage their entrepreneurship capacities and provide them with additional income, recovering the costs of the project.
Use a digital platform and application to track, enable, incentivize and measure interactions between clients and CHPs within the program.
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need to miss work, wait in long lines or walk long distances to obtain their method because services were delivered right to Marieta’s doorstep.
Community-Based Distribution of DMPA-SC by Community Health Promoters The CBD model was designed to bring unique benefits in the distribution of modern contraceptives to Marieta, including:
Cost Recoverable Model By creating a financially attractive business model for CHPs to work in the community, PSI expected them to feel motivated to reach more women and to follow up on supplying the next injectable, creating a sustainable model for family planning products
» Increased Contraceptive Method Options: DMPASC. DMPA-SC is an injectable contraceptive in a prefilled single-use package, intended to be easy to administer. Compared with the intramuscular
and services. CHPs were initially recruited from our Tem+ activities, and trained on the CBD services and on the administration of DMPA-SC.
DMPA-IM injectable, DMPA-SC requires a simplified injection procedure, increasing its acceptability and use by CHPs. The simplified delivery and training to administer DMPA-SC makes it uniquely suited to home administration and ideal for CHPs to deliver services in hardto-reach rural areas with limited health system infrastructure, expanding geographic access to the contraceptive and reaching new users with increased method options.
In order to be cost recoverable, PSI planned for 135 Tem+ CHPs to provide community-based distribution of DMPA-SC to 73,980 women, delivering a total of 206,000 injections of Sayana® Press. This would generate 51,500 couple years of protection (CYPs).4
Technology for Better Follow-Up Through a digital technology platform (first Movercado and then Connecting with Sara (CwS)), PSI tracked, enabled, incentivized and measured client interactions. The digital platform provided tracking tools for CHPs, giving them the needed resources to follow up with clients. This could lead to less discontinuation due to method unavailability because the list of clients registered on CwS made it easier for CHPs to remember when to follow up with clients to re-administer DMPA-SC injections or provide a new cycle of oral contraception.
» Care at Marieta’s Doorstep. By implementing a community-based distribution model, PSI provided more convenient access to modern contraceptive methods to women and girls who live in periurban or rural areas. Women and girls do not XXXXXXXXXX 4.
CYP is the estimated protection provided by contraceptive methods during a one-year period. The CYP is calculated by multiplying the quantity of each method distributed to clients by a conversion factor. For example, it takes 4 doses of Sayana Press to yield one CYP because it takes 4 doses to protect a woman for one year against pregnancy.
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THE PROJECT MODEL In its first year, the project focused on developing a “proof-of-concept” model, which would allow the PSI team to learn and adapt activities rapidly. The following CBD model was developed and implemented in the provinces of Maputo, Gaza, Zambezia and Nampula based on four key interventions:
time. Clients were counseled that this method did not protect against sexually transmitted infections and condom use was recommended if a woman was at risk for a STI. 4. Technology for Client Tracking: Using the digital platform, the CHPs could track clients referred for family planning counseling, as well as the clients to whom they had administered DMPA-SC, enabling them to follow up with each client and keep track of when they needed to re-administer an injection.
1. Demand Creation: Community health promoters went door-to-door to promote family planning counseling sessions. In each interaction, the CHPs registered clients on the digital platform. If the clients were interested in a family planning counseling session, the CHP issued a referral code to a Tem+ clinic.
These four key intervention areas were developed based on a set of assumptions about the unique benefits of DMPA-SC and CBD and were tested and changed throughout the three years of the project based on challenges and lessons learned. Iterations of the model included adding oral contraceptives (OC) to the method mix offered by CHPs and changes in the digital platform used for tracking clients. The CHPs were the key to each intervention, and their motivation and capacity for entrepreneurship were crucial for connecting women and girls to the CBD services in their communities.
2. Service Delivery for First Time Users: After receiving a referral code, the client went to the Tem+ clinic for a comprehensive family planning counseling session. She then had the option to choose a contraceptive method administered by the nurse. 3. Community-Based Distribution of DMPA-SC: If the client chose DMPA-SC as her method, she was eligible to receive the next injection from a CHP at the community level by paying a fee. PSI’s quality guidelines ensured that CHPs offered DMPA-SC within the context of informed choice (ensuring clients have full information about the risks and benefits of each contraceptive method and freedom to decide without coercion, undue influence or fraud) and that clients knew they could switch methods or discontinue use at any
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“I like the convenience of having [Sayana® Press] brought to my workplace, and whenever I have questions I call the CHP and she's always available to answer them.”
CACILDA, 26 YEARS OLD, TEM + BENEFICIARY
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LESSONS LEARNED At the end of the first year (October 2017), PSI saw
approach, to better understand the challenges from
that some clients did not trust the CHP to administer
the users’ perspective, document learnings, and
an injectable since they were used to seeing CHPs
propose innovative solutions.
as health educators. In addition, privacy was very
was designed that outlines Marieta’s needs and
be seen publicly with a nurse or with a CHP. Having
project’s focus shifted from cost recoverability to
community leader engagement was not only
testing out how to reach the most effective model for
important for acceptance of the project in general
service delivery, leading to health impact for Marieta.
but was crucial for acceptance and trust of the CHPs
Marieta’s insights on CBD
in new communities, as well as for the introduction
In order to better understand Marieta and her view of
of innovative services.
As an output of this research, a journey map
important to the clients, and many did not want to
PSI also learned throughout the project that
mapped out these challenges, PSI worked with
touchpoints along her journey to receive CBD
an independent consultant to conduct research
services, including design interventions that were
on the program, using a human-centered design
made to meet these needs and improve activities.
This Research Brought Us Key Insights That Led to Important Changes in the Activities
the project model, PSI surveyed clients with access to the CBD services, asking about their satisfaction
Additionally, PSI learned that CHPs were not
with the product, DMPA-SC, and the service. 760
motivated to travel far distances or do follow-up
beneficiaries from Tem+ Clinics were surveyed. The
work in the communities, despite continued support and training from PSI, because the value of the fees
key insights are described below.
charged per client were often comparable to the
Access
expense of transportation for conducting follow-
52% of the women surveyed had received a method
up visits; this meant the economic gain was not
from a CHP after the first interaction with the Tem+
strong enough to motivate CHPs toward this effort.
nurse. The services were administered mainly at
In light of these project challenges and lessons, the
Marieta’s house, at the market, or in the CHP’s house.
Sites Where Method Is Distributed by CHP
34+66+F 34+66+F 10+90+F 6+94+F 3+97+F 5+95+F
52% One key insight found was that women were initially
program and would introduce the CHP as a trained
skeptical of the CHPs’ qualifications for administering
worker who would follow up with clients within their
family planning methods. This led to changes in
communities. The clients could opt out of the CBD
the CBD model from “opt in” to “opt out,” meaning
model as desired, but having the nurse present the
that nurses would automatically enroll all new
CHP’s expertise in administering family planning
beneficiaries using OC or Sayana Press in the CBD
led to greater trust and willingness to participate.
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of female participants received a method from a CHP
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34%
34%
MARIETA’S HOUSE
MARKET
10%
6%
CHP’S HOUSE
STREET
3%
5%
WORK
OTHER
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Service 95% of the women surveyed were satisfied with the
and referrals only in her neighborhood, surrounding
location where they received the services. The main
the village health center. Signs were displayed
reasons for satisfaction were the quality of service
outside each CHPs’ home to advertise that OCs
(31%), convenience of location (28%) and time
and injectables were available at these locations.
savings (11%). The main reasons contributing to
Each CHP was new to PSI’s work and was selected
dissatisfaction with the services were limited privacy
by a community leader.
(31%) and a lack of trust due to the informality of
Every week, a nurse traveled from the Tem+ Clinic
the location (13%).
(based in Xai Xai city) to Manjacaze Village to run
Price
sessions with first time method users in the CHP’s
The average price reported to buy DMPA-SC was 38
home – or in the client’s home if she preferred.
Mozambican metical (MT) and for the OCs, 35 MT.
This helped increase the clients’ confidence in the
The CHPs made a margin of 28 MT per DMPA-SC and
CHP’s capacity to administer DMPA-SC injections
30 MT for each cycle of OC, or an average of 90 MT
and also their awareness of the CHP’s home as a
every three months for an OC user and 28 MT every
location for service provision. After initial weekly
three months for a DMPA-SC user, as DMPA-SC
visits, the CHPs were responsible for following up
is administered every three months. This adds up
on re-administration of the method.
to approximately 3,693 MT a month, in addition to
Seeing this new model, the District Health Authority
the CHPs’ base salary, for a total of approximately
became interested in using CBD activities to help
6,647 MT per month. (For reference, the minimum
reduce the burden of family planning services at the
wage in Mozambique is about 4,308 MT per month.)
local health facility. With this in mind, PSI trained
Based on these lessons and Marieta’s insights, PSI
nurses from the public health center so she could
adapted project activities and built a final innovative
refer clients using OC or DMPA-SC to the CHP.
CBD project model called, the “Manjacaze Model.”
Challenges and lessons learned throughout the
The Manjacaze Model
project helped PSI to iterate upon the project
Built on key project insights, the Manjacaze Model
activities to ultimately build a more effective model.
reduced the travel and follow-up burden for CHPs
However, the project’s challenges also shifted focus
by basing family planning services out of their
from the goal of cost recoverability, which could
homes. Each CHP was responsible for conducting
only be achieved after effectively addressing the
demand creation activities and providing services
model’s challenges.
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Below Are Additional Lessons Learned From the Project and How They Impacted Activities ORIGINAL HYPOTHESIS
Below Are Additional Lessons Learned From the Project and How They Impacted Activities
LESSON LEARNED
CHANGES / ACTIONS
IMPACT
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CHPs will enroll Marieta in CBD.
TRUST: Marieta was not inclined to receive family planning services from a CHP if they already had a relationship with a nurse. They were used to seeing CHPs as educators, not health workers.
An ‘opt-out‘ model was established so that the nurse would automatically enroll every short-term method user in CBD service. The nurse would then introduce the client to the CHP to immediately build trust and establish the relationship.
This change allowed for trust to be built between the clients and CHPs regarding their capacity to deliver services by having a certified provider verify the CHP’s credibility. It resulted in a 33% increase of daily enrollments compared to the original model.
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Nurses and CHPs will assign and organize clients for household service delivery.
MOTIVATION: As a result of this approach clients were geographically scattered, which led to high costs for the CHPs to travel to follow-up visits. Since travel costs were often greater than the margin they earned from delivering services, this did not motivate them to follow up on clients located far away.
CHPs were assigned to their own geographical area so they did not need This change allowed the CHPs to conduct both demand creation and to travel long distances. follow-up visits in their own communities since they no longer needed to travel long distances and incur extra costs to do their work.
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CHPs will be able to pick up the business model and feel motivated to follow up on clients.
CHPs PROFILE: PSI leveraged CHPs from other PSI Mozambique Tem+ activities that did not have an entrepreneurial focus, so only a few of the CHPs understood the importance of proactively following up with clients. Most preferred to conduct demand creation activities at the clinic, which fell within their comfort zone.
PSI started activities from scratch in a new location (Manjacaze Village) The community leader needed to recruit CHPs to ensure their support to understand how new CHPs with no experience or background in PSI’s of the project. This led to challenges because the CHPs the community activities would perform. leaders had chosen did not necessarily have a “business skillset,” although PSI encouraged this profile. This created a team of CHPs who were not comfortable delivering on the business goals of the project. Only three out of the eight CHPs from Manjacaze displayed strong business skills and were proactive in conducting follow-up visits. It seemed that the amount of extra income generated from follow-up visits was not strong enough motivation for the other CHPs to regularly conduct this work.
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Movercado will send SMS reminders to clients and CHPs, leading to efficient follow-up management.
TRACKING CLIENTS: Initial digital application failures with Movercado left a gap in follow-up reminders. CHPs then managed follow-up appointments on paper and PSI was not able to track clients.
PSI switched from Movercado to a customized PSI application called The CHPs were better able to manage their clients, knowing exactly who, “Connecting with Sara” to track clients and follow-up management. when and where to follow up with each client.
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Most clients will have cell phones to enroll in follow-up on the digital CELL PHONE OWNERSHIP: Clients enrolled in the province of Maputo platform, Movercado. had >80% cell phone ownership and showed a willingness to enroll in the digital application. However, outside of Maputo, there was significantly less cell phone ownership.
PSI piloted and implemented Connecting with Sara, which enables clients to be electronically enrolled and tracked without a cell phone.
PSI was able to track and conduct follow-up with all clients (with and without a cell phone), sharing an SMS referral code with clients who had a cell phone or a paper referral code for clients without a phone.
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The initial project was designed for community Sayana® Press distribution INCLUSION OF OC: Oral Contraceptives (OC) were found to be the preferred among women who preferred this method. method of contraception for southern Mozambican women.
As OC were easy to provide and could fit in the CHPs’ basket of products, Though introduction of OCs to the product basket led to fewer DMPA-SC they were added to the products provided. distributed, increasing the methods provided led to more stable and higher income for the CHPs and more contraceptive methods for Marieta to choose from.
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Because it delivers products directly to their door, CBD provides clients with a unique benefit.
FREE DISTRIBUTION: Other nonprofit organizations increased communitybased distribution of free products and services in the same locations that PSI was selling these products and services. All of the products and services PSI offered then had to compete with free distribution.
PSI reviewed the locations where PSI nurses were doing mobile activities The organizations doing free distribution were conducting mobile activities and adjusted the routes so that products and services were not being sold as well, so PSI was not successful in finding new areas to conduct work in areas saturated by free distribution. where there was no competition from free distribution. This significantly impacted success in reaching target indicators.
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Nurses will be motivated to recommend clients to the CBD program.
HIGH NURSE ROTATION: Mozambique faces a large demand but low supply of nurses. Due to the resulting high turnover, PSI faced the continuing challenge of keeping high-quality nurses on staff.
A floating nurse was added to the provincial teams to serve as back-up, The floating nurse was able to provide coverage for some of the nurse when needed. turnover, but often coverage was needed for more than one nurse.
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The new digital platform, Connecting with Sara, will perform well and function offline.
TECH SETBACKS: One of the challenges that comes with technology is the dependence on a good Internet connection, which in some regions is not available. The application had some unexpected bugs and errors.
PSI created communication groups on existing platforms (Microsoft Teams Operations ran more smoothly with quick replies to different technological and Whatsapp) with staff from the central office so that technological issues and improved timing of repairs. issues could be immediately reported and resolved.
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CHPs will be able to work in communities where they have never worked COMMUNITY LEADERS ARE KEY: Community leaders have always played before. a role in engaging the community for the intended activities. They proved additionally crucial in building trust between the community members and CHPs, as well as introducing innovative services.
PSI’s teams went back to the community leaders to have them present The CHPs felt more respected in their work after having the community CBD services in community meetings and have them help introduce the leaders’ support. new services to the community.
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The project team will be stable, with a project champion to follow up on STAFF TURNOVER: The project team was not stable throughout the course the project from beginning to end. of the project, which brought some challenges in keeping the project upto-speed since the new team needed time to adapt and learn the project.
As transitions occurred, staff were immediately replaced and new staff were The team was able to keep up with ongoing activities and new staff brought onboarded to the project. Based on the project’s lessons learned, new staff different and innovative thinking to the project, including human-centered was recruited with different skillsets, including technological capabilities. design activities.
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The set deliverables will be timely.
DELAYS: Throughout the project, the team faced several challenges that delayed the set delivery timeline, which included delays in getting approvals from the local authorities and delays in developing the necessary digital applications.
The team ensured that challenges and delays were effectively communicated Due to the initial delays and set-backs, the project was extended for so that deliverables could be adjusted accordingly. 6-months.
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The CHP team will be recruited at the start of the project, and we’ll be able to maintain the minimum number of active providers.
CHP TURNOVER: The turnover of CHPs throughout the course of the project was very high and it proved quite difficult to recruit and keep CHPs on the team.
A higher number of CHPs were trained than needed to account for high turnover rates.
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PSI was able to keep a steady number of CHPs, although it was lower than forecasted even with the additional recruitments.
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KEY PROGRAM INDICATORS
CBD Activities Coverage – March 2018 to March 2019
Monitoring and evaluation (M&E) were conducted
quality assurance reports, registry books, Salesforce
on a monthly basis to ensure project activities were
and Connecting with Sara, and provided actionable
effectively implemented. The key project indicators
evidence for programmatic decisions.
were gathered using tools provided by PSI such as
PROJECT ACCOMPLISHED TARGETS
KEY PROGRAM INDICATORS Number of signed service agreements with CHPs* Number of women reached with a sensitization session by a CBD CHP** Number of women who are administered DMPA-SC by a Tem+ nurse* Number of women who received an OC from a Tem+ nurse**
99
135
(average from the 3 years)
-
284,000
170,484
7,571
% 73%
4%
-
19,710
168,141
26,574
-
40,280
Number of trained providers*
30
40
133%
Number of CHPs trained*
135
208
154%
Number of women who are administered DMPA-SC by a CHP* Number of women who received an OC by a CHP**
16%
* Key Indicators, agreed at the start of the project ** These numbers are gathered through CWS, from March 2018 to June 2019
Due to the challenges presented in the table above,
reached through sensitization sessions. From March
PSI was not able to reach the proposed distribution
2018 to May 2019, CHPs reached more than 284,000
targets for DMPA-SC, but realized significant
clients within the project’s communities of focus. From this, approximately 33% of women received a
learnings on this innovative approach that will be used
method that was delivered through a nurse or CHP.
in PSI projects for CBD and DMPA-SC going forward.
Although this coverage was mainly in urban areas,
Using the Connecting with Sara digital platform, PSI
significant rural reach was observed in some of the
was able to measure the number of clients that CHPs
rural provinces.
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Based on the populations reached, a high percentage of women were over 25 years old (52%), followed by women 20-24 years old (32%) and a lower share of women under 19 years old. This is likely because older women are better able to pay for products
and services. Twenty-seven percent of the women reached by CHPs showed an interest in attending a family planning consultation. Of this group, 54% actually attended a session.
DMPA-SC DISTRIBUTED DISAGGREGATED BY AGE, PROVINCE, USERS LOCATION
USERS
≤ 19 YEARS
20 - 24 YEARS
≥ 25 YEARS
TOTAL
ALL USERS
Maputo
New Continuing
407 1,259
845 2,413
1,330 4,948
2,582 8,621
11,203
Gaza
New Continuing
521 626
1,332 1,611
2,143 3,047
3,996 5,284
9,280
Zambezia
New Continuing
212 862
345 1,324
518 1,954
1,075 4,140
5,215
Nampula
New Continuing
254 1,154
384 2,172
745 2,362
1,383 5,688
7,071
5,295
10,427
17,047
32,769
32,769
TOTAL
SOURCE: Monthly Register Book and SFDC
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MAVERICK COLLECTIVE LEGACY CBD Approach: The approaches and tools from
capture basic information about their families and
the CBD model will be adapted to inform targeted
contraceptive choice. The application has become a
urban fee-based distribution in the PSI network. PSI
valuable addition to measurement and evaluation of
learned from this project that adolescents desire
the project and provides more qualitative information
service provision outside of health facilities and
on Marieta’s behavior.
that this is a promising channel to create access
PSI Mozambique is the DMPA-SC focal partner in
to contraceptives for girls and women who choose
country for the DMPA-SC Access Collaborative,
short-term methods.
advising the government on the acceleration of DMPA-
By the end of 2018 the Government of Mozambique
SC. In 2020, 90% of the injectables purchased by the
suspended the distribution of modern contraceptive
public sector for Mozambique will be sub-cutaneous.
methods in schools with the exception of OCs
Additionally, with funding from the Children’s
and condoms. Following this, PSI Mozambique is
Investment Fund Foundation, PSI supported the
in discussions with the Ministry of Health about
Ministry of Health in the development of a National
establishing a community-based distribution program
Roll Out Plan for DMPA-SC which is now under review
in school catchment areas so adolescents can resupply
by the Technical Working Group for Family Planning
on short-term methods in a convenient location.
(TWG). This plan defines the activities for roll out in
Connecting with Sara: The CwS app will continue to
the public sector and outlines the potential pathway
be used in other programs, providing data for other
for client self-administration and private sector
programmatic activities. It is currently being used
sales. PSI has also recently developed counseling
in an USAID-funded Integrated Family Planning
tools for nurses that reflect the different options for
Program (IFPP) to map clients’ locations and
injectables, and which are to be reviewed by the TWG.
60
800,000
Mobilized $60 million in resources for girls and women
Helped more than 800,000 girls and women live healthier lives
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60 millions
800,000
Mobilized $60 million in resources for girls and women
Helped more than 800,000 girls and women live healthier lives
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