Community-Based Family Planning
Review the Evidence
40 years of evidence; one comprehensive database
POPLINE is the world’s largest free database of family planning and reproductive health literature. An international resource, POPLINE helps program managers, policy makers, and service providers in low- and middle-income countries and in development-supportive agencies and organizations gain access to scientific articles, reports, books, and unpublished documents. POPLINE has a wealth of evidence on the importance of community-based access to family planning options:
- Community-based family planning
- Community-based distribution
- Community health workers
- Drug shops
- Mobile outreach
Community access and innovation
Exploration of the Potential of Private Sector Pharmacies to Offer Family Planning Services in Senegal (Evidence Project, 2018; PDF, 1.09MB) introduces a package of two briefs and three reports of interest to policy makers and program designers around the world who are exploring the process of task shifting family planning services. It includes policy recommendations for the Government of Senegal, for pharmacists and their professional organizations, and for technical and financial partners. While the synthesis brief is available in French and English, the reports are only published in French.
Building Evidence to Support the Provision of Implants at Community Level Through Task Sharing in Kaduna and Cross River State, Nigeria (E2A, 2017; PDF, 1.8MB) assessed the effects of Community Health Extension Workers (CHEWs) providing implants on contraceptive uptake at health facilities in select Local Government Areas (LGAs) of the Cross River and Kaduna state, Nigeria. Informed by the successful introduction and scale-up of implant provision by Health Extension Workers in Ethiopia, the USAID-funded Evidence to Action (E2A) Project implemented a demonstration project and documented a scale-up process for provision of implants through task sharing to CHEWs. Evidence from the study can be used to support operationalization of a recent policy shift in Nigeria that expands CHEWs’ family planning tasks to include provision of implants.
Task-Sharing and Other Community-Based Innovations that Increase Access to Injectables and Implants (E2A, 2017; PDF, 877KB) describes task-sharing approaches, or alternatives to task-sharing, applied by E2A over the last three years in Burundi, Democratic Republic of the Congo (DRC), Mozambique, and Nigeria. These approaches have brought safe and effective clinical contraceptive methods—largely, injectables and implants—in arm’s reach of women and girls, resulting in significant increases in their use.
FHI 360, through USAID’s Advancing Partners & Communities project, conducted a randomized controlled trial in Malawi comparing continuation rates of women who self-injected Sayana® Press (DMPA-SC) and women who received it from a provider, including CHWs. Self-Injection of DMPA-SC Leads to Improved Continuation Rates (APC, 2017; PDF, 691KB) summarizes the results: Researchers found significantly higher rates of continuation among women randomized to self-administration compared to those who received the same method from a provider, including CHWs. The trial provides evidence that CHWs can safely train women to self-inject DMPA-SC and that community-based provision of injectables for self-injection in low-resource settings is safe and feasible.
PATH’s Self-Injection Best Practices Project in Uganda aims to evaluate and identify optimal DMPA-SC self-injection program models across sectors. A new brief (2017; PDF, 484KB) provides an overview of this project's process, progress, and insights learned to date. New tools, including a one-page job aid for client training and support, have been developed as more providers receive training in offering self-injection to their clients.
Within the health sector, the integration of family planning (FP) programs with other services has a long history. There are two key reasons for integrating community-based FP with other health services: evidence from implementation studies shows that linking FP to other health and non-health services benefits clients and programs, and a policy environment supportive of CBFP already exists in many countries. The Added Value of Integrating Family Planning into Community-based Services: Learning from Implementation (APC, 2017; PDF, 585KB) provides details on the design, techniques, and strategies used by Advancing Partners and Communities to integrate FP with a range of services—HIV and AIDS, MNCH, PHE, economic development, WASH, and sustainable development for vulnerable families.
Uganda has 6,363 registered drug shops and many more unregistered ones serving rural areas where 80% of the population lives; unmet need for family planning is high. Managing the policy advocacy process: Drug shops’ provision of injectable contraception in Uganda (APC, 2017; PDF, 771KB) supports the evidence that private drug shops could offer an opportunity to expand access to family planning, as they are commonplace in rural areas and support a sustainable commercial market for health products. The Ministry of Health (MOH) is leading an advocacy process to ultimately allow the legal and safe provision of injectable contraception by registered drug shops in Uganda. This case study captures several of the key developments in the ongoing advocacy process to support this service delivery channel and the lessons learned thus far.
Uganda's MOH is committed to supporting alternative distribution channels for the private sector and to scaling up innovative approaches such as community-based distribution, outreach, social marketing, social franchising, and youth-friendly service provision. Delivery of Injectable Contraception by Drug Shop Operators in Uganda: Research and Recommendations (APC, 2016; PDF, 623KB) makes the case that drug shops and other private-sector providers offer complementary services to help government service providers meet the growing demand for family planning, specifically injectable contraceptives, and should be included in the network of community-based family planning providers in Uganda.
CBFP programs emphasize the provision of a full range of FP methods as a key aspect of quality programming. This underscores the need to create strong referral systems from community-based services to higher-level facilities for methods that are not available locally, such as long-acting and reversible contraception and permanent methods (LARC/PM). However, evidence is limited on the most effective, cost-efficient, and scalable ways to provide and track referrals. APC's Situation Analysis of Community-Based Referrals for Family Planning (2016; PDF, 1.65MB) reviews the evidence on current models of community-to-facility referrals for LARC/PM, provides recommendations on promising models that should be tested for effectiveness, and suggests an agenda for future research.
Evidence summaries: the HIPs briefs
The High Impact Practices in Family Planning (HIPs) team at USAID has developed briefs that synthesize the evidence and provide recommendations on how to implement selected HIPs.
Community Group Engagement: Changing Norms to Improve Sexual and Reproductive Health (2016; PDF, 690KB) describes the evidence on and experience with community group engagement (CGE) interventions that aim to foster healthy sexual and reproductive health (SRH) behaviors. The distinguishing characteristic of CGE interventions from other social and behavior change (SBC) interventions is that they work with and through community groups to influence individual behaviors and/or social norms rather than shifting behavior by targeting individuals alone. Specifically, community support can shift individual behaviors, including contraceptive behaviors, either by changing norms or individual knowledge and attitudes.
When appropriately designed and implemented, community health worker (CHW) programs can increase use of contraception, particularly where unmet need is high, access is low, and geographic or social barriers to use of services exist. CHWs are particularly important to reducing inequities in access to services by bringing information, services, and supplies to women and men in the communities where they live and work rather than requiring them to visit health facilities, which may be distant or otherwise inaccessible. Community Health Workers: Bringing family planning services to where people live and work (2015; PDF, 829KB) discusses the evidence for CHW programs, as well as the support and training CHWs need to be successful.
Mobile outreach services address inequities in access to family planning services and commodities in order to help women and men meet their reproductive health needs. Evidence demonstrates that mobile services can successfully increase contraceptive use, particularly in areas of low contraceptive prevalence, high unmet need for family planning, and limited access to contraceptives, and where geographic, economic, or social barriers limit service uptake. When well-designed, they help programs broaden the contraceptive method mix available to clients, including increasing access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs). Mobile outreach services: expanding access to a full range of modern contraceptives (2014; PDF, 429KB) describes the role of mobile outreach programs as a means of reducing inequities in access to family planning services (particularly LARCs and PMs), discusses the potential contribution of these programs, and outlines key issues for planning and implementation.
Small commercial drug shops and pharmacies are often the first line of health care in poor countries, especially in rural areas that have very few private or public clinics. Evidence shows that with appropriate training and support, staff can facilitate the use of modern contraception, especially in urban slums and rural areas where the unmet need is high, access is poor, and health-worker shortages and other barriers prevent men, women, and youth from accessing family planning services. Drug Shops and Pharmacies: Sources for family planning commodities and information (2013; PDF, 797KB) describes the importance of these outlets for distributing commodities and information and outlines key issues for planning and implementing programs to support pharmacy and drug-shop staff. In 2017, technical experts hosted a complementary webinar.
Open access, peer-reviewed journal
The Global Health: Science and Practice Journal contains many peer-reviewed articles on community-based family planning and related topics.
Agarwal S, Lasway C, L’Engle K, Homan R, Layer E, Ollis S, et al. Family Planning Counseling in Your Pocket: A Mobile Job Aid for Community Health Workers in Tanzania. Glob Health Sci Pract. 2016;4(2):315-325. Using mobile job aids can help CHWs deliver integrated counseling on family planning and HIV/STI screening by following a step-by-step service delivery algorithm. Lessons learned during the pilot led to the development of additional features during scale-up to exploit the other major advantages that mHealth offers, including better supervision of health workers and accountability for their performance, improved communication between supervisors and workers, and access to real-time data and reports to support quality improvement.
Weidert K, Gessessew A, Bell S, Godefay H, Prata N. Community Health Workers as Social Marketers of Injectable Contraceptives: A Case Study from Ethiopia. Glob Health Sci Pract. 2017;5(1):44-56. Volunteer community health workers (CHWs) administered injectable contraceptives to women in the community for a small fee while providing counseling and referrals for other methods. Over nearly 3 years, more than 600 CHWs provided an estimated 15,410 injections. The model has the potential to improve sustainability of community-based distribution programs by incorporating social marketing principles to partially recover commodity costs and compensate CHWs.
Gueye B, Wesson J, Koumtingue D, Stratton S, Viadro C, Talla H, et al. Mentoring, Task Sharing, and Community Outreach Through the TutoratPlus Approach: Increasing Use of Long‐Acting Reversible Contraceptives in Senegal. Glob Health Sci Pract. 2016;4 Suppl 2:S33-S43. Mentoring, task sharing, and community outreach at 100 rural facilities in Senegal led to an 86% increase over 6 months in the number of women choosing long-acting reversible contraceptives (from 1,552 to 2,879). Concurrent improvement of facilities and provider skills, coupled with the application of Senegal’s task-sharing policy, are increasing the range of contraceptive methods available to women throughout the country.
Charyeva Z, Oguntunde O, Orobaton N, Otolorin E, Inuwa F, Alalade O, Abegunde D, Danladi S. Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria. Glob Health Sci Pract. 2015;3(3):382-394. With training and supportive supervision, male and female Community Health Extension Workers (CHEWs) in Nigeria safely and effectively provided contraceptive implants, and virtually all clients said they were satisfied. Most CHEWs achieved competency after five client insertions. However, the CHEWs provided only an average of four insertions per health facility per month. Realizing the true potential of providing implants calls for a context with dedicated providers and robust outreach.
Schaefer L. Task Sharing Implant Insertion by Community Health Workers: Not Just Can It Work, but How Might It Work Practically and With Impact in the Real World. Glob Health Sci Pract. 2015;3(3):327-329. Demonstrating that a health service, such as providing contraceptive implants, can be safely task shared to less highly trained workers is crucial but is only one step toward effective implementation at scale. Providers need dedicated time, enough clients, supplies, supervision, and other system support, allowing them to maintain their competency, confidence, and productivity.