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Increasing Community Access to Contraceptive Injectables in Kenya
The Government of Kenya amended its national family planning guidelines to allow community-based distribution of injectable contraceptives by community health workers (CHWs), vastly increasing women’s access to family planning in the country’s most underserved and hardest-to-reach communities. Kenya’s Director of Public Health and Sanitation and Director of Medical Services jointly signed a policy circular on 28 November 2012, to make the change . The amendment is the culmination of a focused advocacy strategy facilitated by the Advance Family Planning (AFP) initiative and its lead Kenya partner, Jhpiego. Advocacy efforts relied heavily upon disseminating evidence of the safety and effectiveness of CHWs’ provision of injections and galvanizing support from key medical, nursing, and midwifery leaders.
The Need for Injectable Contraceptives
According to Kenya’s most recent Demographic and Health Survey, over one in four women (26%) have an unmet need for family planning, i.e., they would like to prevent or delay pregnancy, but are not using contraception. The national contraceptive prevalence rate (CPR) is 46%, meaning that less than half of currently married women aged 15-49 are using a method of contraception. Regionally, the CPR ranges widely, from 67% in the Central Province to 4% in the North Eastern Province . These stark regional disparities have been attributed to, among other things, the lack of qualified health workers who can administer family planning services . Because injectable contraceptives are the most popular form of family planning in Kenya2, advocates have long argued that the community-based distribution of injectable contraceptives could mitigate Kenya’s staffing shortage and increase the CPR in its hardest-to-reach rural areas.
Disseminating Data to Task-sharing Stakeholders
Since discussions first began in 2006, principal challenges to allowing CHWs to provide injectable contraceptives included a perceived lack of evidence about its feasibility, acceptability, and safety as well as concerns from other cadres of health providers about the effects of task sharing with CHWs. A pilot demonstration project in Thakara District conducted in 2009 and 2010, a collaborative effort among Kenya’s Ministry of Public Health and Sanitation, FHI360, and Jhpiego, through the U.S. Agency for International Development (USAID) APHIA II Eastern program, collected the data needed to respond to these challenges. Namely, the Thakara project found that community-based distribution by CHWs led to high-quality service delivery, with no reported adverse effects from any of the 2,453 injections and a fivefold increase in family planning uptake among women of reproductive age, from 9% to 46% over the project period. However, the results of the project were not disseminated to the technical staff in the Ministry of Health or professional associations who influenced national policy.
In early 2012, AFP conducted a workshop to enable a group of family planning advocates to create and implement a strategy for bringing about the policy change. The workshop was hosted by the then-head of the Division of Reproductive Health for the Ministry of Public Health and Sanitation, Dr. Bashir Issak, who served as an official link to both the Director of Public Health and Sanitation (DPHS) and Director of Medical Services (DMS). Using a focused advocacy approach adapted from the Spitfire Strategies Smart ChartTM, the workshop participants set the SMART (Specific, Measurable, Attainable, Relevant, and Time-bound) advocacy objective: that the DMS and DPHS sign a joint policy circular to amend the National Family Planning Guidelines to allow provision of the contraceptive injectable "DMPA" by CHWs.
Next, the participants identified six decisionmakers whose support for the policy amendment was deemed critical: the DMS, DPHS, the Chief Nursing Officer who advised them, and three leaders of national nursing and midwifery professional associations. The participants then brainstormed ways to deliver their advocacy message, deciding to formally disseminate the weighty findings of the Thakara project at both the district and provincial levels to increase publicity before using the data in meetings with each of the key audiences. Finally, the participants set a deadline for achieving the policy change: six months.
Garnering Support from Key Stakeholders
Delivering the evidence-based advocacy argument based on the Thakara project’s findings galvanized an important champion in the Director of Medical Services for the Eastern Province. After admitting his initial skepticism, the director said: "I am now completely convinced that [community-based distribution] is effective and that CHWs can work and change the health of the people they serve." The provincial nursing official vocalized similar support. Both opinions were influential to persuading the other four decisionmakers.
Different decisionmakers focused on different data from the Thakara project. The midwifery association, for example, was interested in the positive effects of community-based distribution on antenatal care and skilled delivery attendance, while the Chief Nursing Officer and one of the nursing associations were interested in the absence of adverse events. The Director of Medical Services sought data beyond that collected by the Thakara project regarding family planning uptake in other provinces and districts.
In all cases, deferring to the interests of each stakeholder and adapting the advocacy message with available data led to the necessary endorsements for the policy change. One of the nursing associations conditioned its endorsement upon supportive supervision of all CHWs offering injections and on the prioritization of community-based distribution in the hardest-to-reach areas. AFP was able to address these conditions in its final draft of the policy circular. In November 2012, just over six months after the initial workshop, the policy circular was signed.
AFP’s SMART advocacy approach works well to plan for policy changes, but the approach must be adapted to each local context. The AFP-supported workshop that followed the Thakara project presented the first opportunity for family planning stakeholders to create an advocacy strategy to achieve community-based distribution of injectable contraceptives, largely through focused dissemination of existing data to key decisionmakers. However, an advocacy strategy does not always proceed in the order planned: Opportunities to meet with stakeholders must be taken whenever possible, and unplanned events, such as a nurses’ strike, tested advocates’ flexibility and improvisational skills. It is also important to recognize the limited engagement of most stakeholders and to identify early on the stakeholders who will be best equipped to move the strategy forward.
Ensure that there is sufficient evidence to support the proposed policy and convince technical stakeholders. The findings of the Thakara project were important, if not essential, to the endorsements of each key decisionmaker. The project concluded in 2010, but its results had not been formally presented by the time that the advocacy strategy was developed in early 2012. Public dissemination of research findings is often necessary to legitimize them and make them accessible to the technical stakeholders who advise the ultimate policymakers.
Use existing relationships and defer to stakeholder interests as much as possible when "making the case" for the proposed policy. The involvement of Dr. Bashir Isaak and other stakeholders who already held the trust of key decisionmakers enabled meetings that would not have occurred so quickly and easily otherwise. Deferring to stakeholder concerns wherever possible makes endorsement much more likely; in this case, acknowledging that one of the nursing associations had a strong interest in supportive supervision and adding that supervision to the policy led to its successful approval.
The amendment to Kenya’s family planning guidelines to permit the community-based distribution of the injectable contraceptive "DMPA" should help increase community access for family planning services through task sharing with CHWs. The advocacy strategy behind this ground-breaking policy change involved substantial reliance on demonstration project data and deference to the concerns of other cadres of health providers. Advocacy efforts continue as this policy is implemented and as Kenya’s national and local health authorities undergo major political changes.
1. Ministry of Public Health and Sanitation, Office of the Director. 28 November 2012. Provision of Depot Medroxyprogesterone Acetate (DMPA) by Trained Community Health Workers (CHWs). Nairobi, Kenya.
2. Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008-09. Calverton, Maryland. ["Kenya DHS 2008−09."]
3. National Council for Population and Development. 2012. Regional Variations in Contraceptive Use in Kenya: How Can the Gaps be Bridged? Nairobi, Kenya.
Photo by CGIAR, courtesy of Flickr Creative Commons.