CBFP Program Challenges
Successful CBFP programs increase people’s access to FP services, increase knowledge about FP, ensure quality FP services and address the social and political environment. However, there are settings where CBFP is not an appropriate strategy. For example, when FP awareness and knowledge are high, contraceptive prevalence is relatively high, and a sufficient number of fixed health facilities are accessible and offer a range of methods. There are also examples where the need for CBFP services has naturally decreased as the demand for FP and the quality and access to the health services and facilities increased. In this case, CBFP, and CHW provision of FP in particular, can be seen as an interim strategy to raise demand and access, recognizing that once this is accomplished, the expense for services at the community level may no longer be necessary.
If you are implementing one or more CBFP approach, experience from around the world reveals special considerations to address for operating an effective, sustainable CBFP program. The following represent some of the most common lessons and challenges:
- Maintaining a cadre of motivated and well-trained CHWs that will remain in place after a project ends requires creativity and planning.
- Supervising, mentoring, and supporting CHWs and drug shops that are geographically scattered can be complex and costly, yet these components are essential for maintaining the quality of the program.
- Establishing and maintaining links to health facilities that provide other methods is an ongoing task.
- CHWs, drug shops and mobile outreaches have limits in the range of methods they can distribute, and thus clients may still need to travel to a health facility for their method of choice.
CBFP programs (especially those working with CHWs) should take into account the following:
- Logistics and supplies : A CBFP program depends on having a reliable source of commodities and supplies. This is often through the local health center, although it may also be through the local social marketing distribution system. Products are typically procured with money obtained through cost recovery, and/or may be subsidized by the government or donor. CHWs must know the procedures for replenishing their FP commodities and other supplies, know who is responsible for resupplying, and have a system to maintain good communication with their supplier.
- Training and supervision : A CBFP program should develop criteria to identify and select women and men to serve as effective CHWs. This should be done in consultation with community members. Upon selection, training for CHWs takes place, usually lasting at least two weeks. Programs should also include a plan for regular refresher training of CHWs and on-the-job training as part of regular supervision. For supervision and support, CHWs should be linked to the local health center and a government health worker. Good supportive supervision improves the quality of FP services, retention, and motivation of CHWs. Proper supervision is important to ensure the quality of CHW counseling skills, provide feedback to CHWs, encourage and support CHWs, and identify areas for improvement.
- Referral system: A CBFP program will need to create or strengthen the referral systems for the health facility to increase client access to LAPMs. Facility workers can also refer clients back to CHWs, who can monitor FP clients for side effects and answer clients’ questions about methods they obtained at the facility.
- Volunteer management and motivation: CBFP programs exist with both paid and volunteer CHWs. Volunteer CHWs typically receive modest incentives, such as supplies and increased status in the community. Retaining volunteer CHWs can sometimes be addressed by expanding the “portfolio” of the CBFP program to include other socially marketed products such as insecticide-treated bed nets, and/or expanded health roles, which increase their credibility, status, and access to training allowances.
- Scale and sustainability plan: CHW programs may be implemented on a relatively small scale due to the level of training and support required. Ownership at the ministry of health is essential for finding long-term support for supervision and refresher training to sustain CHW programs.