Liberia: EPI/FP Final Assessment Report
From March to November 2012, Liberia’s Ministry of Health and Social Welfare (MOHSW), with technical support from the Maternal Child Health Integrated Program (MCHIP), supported by the U.S. Agency for International Development (USAID), piloted a model for integrating the service delivery of immunization and family planning (FP) in 10 health facilities in Bong and Lofa counties. The approach involved vaccinators providing a few short, targeted FP and immunization messages and same-day FP referrals to mothers bringing their infants to the health facility for routine immunization. Both the MOHSW’s Expanded Program on Immunization (EPI) and the Family Health Division provided input on the design of the model and selection of facilities for the pilot. Immunization services at fixed facilities (as opposed to outreach services) were identified as the primary integration platform, given that in Liberia fixed facility services cover a greater proportion of infants and service provision in fixed facilities tends to be more stable and consistent. Fixed facilities also permit a greater degree of privacy—which stakeholders viewed as a particularly sensitive point with regard to contraceptive use by mothers of young infants.
A final assessment was conducted in December 2012 to assess the outcomes of integrated service delivery. The assessment relied on the following sources of data: service statistics (both EPI and FP) collected during the MCHIP/MOHSW monthly supervision visits to each participating facility; observations during supportive supervision visits and training activities; MOHSW EPI data for pilot facilities and all other facilities in Bong and Lofa counties for 2011 and 2012; and interviews and focus group discussions (FGDs) with clients, service providers, program managers, and partner agency representatives. Key findings include the following:
· Both counties experienced large increases in the numbers of new contraceptive users. Comparing the intervention period (March–November of 2012) with the same period of 2011, the number of new contraceptive users at participating facilities increased by 90% in Lofa County (517 to 983) and 73% in Bong County (1,182 to 2,039) for a total increase of 1,323 new contraceptive users above the same period of the previous year. For March–November 2012, the number of new contraceptive users in the pilot sites included women who had actively committed to use the lactational amenorrhea method (LAM). LAM was not routinely tracked in FP registers in 2011, but routine counseling on LAM by FP providers and active utilization of LAM were suspected to be very low prior to the intervention. No concurrent major efforts to improve the provision or utilization of FP had been introduced at these sites between 2011 and 2012.
· FP users who were referred from EPI and accepted a method on the same day accounted for a large proportion of the total number of new contraceptive users in participating facilities. During the pilot period, 44% and 34% of all new contraceptive users in participating facilities in Bong and Lofa (respectively) were same-day EPI-referral acceptors.
· Pilot facilities experienced an increase in the number of doses of Penta 1 and Penta 3 administered. In Lofa, the number of Penta 1 and 3 doses administered at facilities participating in the EPI/FP pilot increased substantially in March–November 2012 compared to the same period of the previous year whereas the number of Penta 1 and 3 doses decreased across all other non-participating facilities in the county. In Bong County, Penta 1 and 3 doses experienced a modest increase, both at participating and non-participating facilities. In both counties, the increase in Penta 1 doses administered outpaced that of Penta 3 doses, resulting in a net increase in the dropout rate. An examination of possible explanations showed that the pilot facilities had a higher than average background rate of dropout prior to participating in the pilot and that, in Bong, the findings were affected disproportionately by one large facility that experienced a drop in immunization due to human resource constraints in 2012. Together, these findings suggest that the changes in immunization were more likely due to broad external factors rather than the integrated EPI/FP service delivery itself. However, future integration efforts should continue to seek ways to minimize dropout rates—a problem that has been noted to challenge immunization services nationwide.
· Activities increased vaccinators’ sense of confidence and value within the health system and community. Vaccinators reported that the integrated service delivery pilot initiative contributed to their sense of confidence and perceived value within the community, and may have helped to improve their communication with clients and attention to immunization recordkeeping.
· Integrated service delivery continued at pilot sites by its own accord even after the pilot phase was completed. Follow-up visits to several facilities in each county conducted three months after the completion of pilot program activities indicated that service providers were continuing to implement the integrated approach in spite of the completion of the pilot program. Vaccinators, FP providers, and supervisors noted the value of the approach for improving uptake of services and increasing communication and collaboration across service delivery areas.
In conclusion, it appears that the key features of the approach were workable, and contributed to strong increases in FP uptake among women in the extended postpartum period. The model can be improved by strengthening the emphasis on immunization communication, thereby assuring a strong platform for referral to FP services. Together, these combined services can contribute to longer birth intervals and improved health outcomes for children, mothers, and families. Modest resources are needed to implement this model, which makes only minor changes in existing health worker practices, adding about two to three minutes per vaccination contact. Resources are needed for training, some changes in supervision, support materials and, in some places, privacy screens. It is hoped that findings from this pilot study will help to inform future efforts to integrate EPI and FP services in Liberia and in other countries.