Community-Based Family Planning Services

 

Welcome to the programmatic area on community-based family planning (CBFP) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. CBFP is one of the subareas found in the family planning (FP) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. CBFP programs bring FP information and methods to women and men, as well as adolescents, in the communities where they live and work, rather than requiring visits to health facilities. The increased access provided by CBFP is particularly important for people living in remote areas, where unmet need for FP is high, access is low, and geographic, social, and religious barriers to using FP exist. Monitoring CBFP is critical to track progress towards national and global goals related to reducing maternal and child mortality. Key indicators to monitor and evaluate CBFP can be found in the links at left.   Full Text Community-based family planning (CBFP) programs bring family planning (FP) information and methods to women and men in the communities where they live, rather than requiring visits to health facilities.  The increased access provided by CBFP is particularly important for people living in remote areas, where transportation is difficult to find or expensive, where little is known about FP, in areas where cultural traditions support early marriage, large families, and where women’s mobility outside the home is restricted.  CBFP is directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health. The Global Health Initiative (2010) includes CBFP under the second principle (to increase impact through strategic coordination and integration) and considers it a key strategy for meeting the large unmet demand for FP services in underserved areas.  Community-based distribution (CBD) programs have been in existence since the 1960s and Pathfinder International, one of the early organizations to establish CBFP and reproductive health (RH) programs, found that working with communities at the grassroots level is an effective way to both improve access and challenge socio-cultural barriers to RH/FP services (Pathfinder Int’l, 2006). In a review of more than 30 years of CBD programs, Prata et al. (2005) found that direct contact with CBD agents resulted in 3 to 10 times the amount of modern contraceptive use, although the costs of CBFP programs can be higher than for other delivery methods, such as public clinics or contraceptive social marketing.  The authors view CBFP as necessary in settings or countries where clinic- or hospital-based distribution are not adequate to meet FP need at the local level and, ideally, when combined with other FP delivery systems (Prata et al., 2005).  As part of the Implementing Best Practices (IBP) initiative, WHO and partner organizations have compared models for community-based RH/FP services with the goal of identifying effective practices worth scaling up.  Participants in the IBP process expressed the need for simple up-to-date tools for community-based health workers leading to the current work on an updated version of the WHO (2005) Decision-Making Tool for Family Planning Clients and Providers for use in the community (WHO, 2010).        The USAID sponsored Knowledge for Health (K4Health) website provides a toolkit for CBFP programs with resources ranging from background, policy and advocacy, to program design, training and monitoring and evaluation (ME).  The Toolkit lists four strategies considered basic to CBFP: (1) use of CBD agents; (2) a community depot system; (3) mobile services; and (4) engaging the private sector.  CBD agents are community members who have been selected, trained, and supervised to educate, counsel, and distribute contraceptive methods to women and men in their village or neighborhood.  In a community depot system, a person (or depot holder who may or may not be a CBD agent) stores contraceptives within the community and distributes them to clients. With mobile services, teams of health care providers travel from health facilities to the communities (or from a higher to a lower-level health facilities) to offer FP services and methods in areas where services are limited or do not exist. While this approach takes more planning, it greatly improves method choice at the community level. Private sector entities can be important partners in developing and making CBFP programs sustainable.  Management Sciences for Health (MSH) provides a website dedicated to management resources with guidelines and links for community-based services. MSH (2010) emphasizes that gender roles and norms are especially important factors to consider in designing, managing, and delivering CBFP and RH services. CBFP successes have led to continued and expanded programs in underserved areas, with the accompanying need for ME of program components and resulting levels and trends in service utilization.  The five core indicators selected for this database cover training, access to and quality of services, and client use. While specific to CBFP, these indicators also correspond with more general indicators in the database technical area on Family Planning. The USAID Flexible Fund resource presents a list of recommended core indicators for implementing and evaluating RH/FP programs with an annotated Appendix (6) containing links for CBFP (USAID, 2008).  Additional indicators relevant to CBFP, such as local rapid assessments and questionnaires for CBD agents and supervisors can be found in the MSH website.  __________    References: Management Systems for Health (MSH), 2010, Managing Community Health Systems, The Managers Electronic Resource Center Website, Cambridge, MA: MSH.  https://www.msh.org/blog-tags/managers-electronic-resource-center Pathfnder International, 2006, Improving reproductive health through community-based services, Watertown, MA: Pathfinder Int’l Prata N, Vahidnia F, Potts M, Dries-Daffner i., 2005, Revisiting community-based distribution programs: are they still needed? Contraception. 72; 402-7.   USAID, 2008, USAID Flexible Fund Guidance for Grantees, Washington, DC: USAID. http://www.flexfund.org/resources/grantee_tools/guidance_docs.cfm   USAID/K4Heath, 2010, Community-based Family Planning Toolkit, Knowledge for Heath, USAID Office of Global Health Website, www.k4health.org. http://www.k4health.org/toolkits/communitybasedfp WHO, 2010, Implementing Best Practices in Reproductive Health: Our first 10years, Geneva: WHO. http://www.ibpinitiative.org/images/OurFirstTenYears2010.pdf WHO / JHPIEGO, 2005, Decision-making tool for Family planning clients and Providers, Geneva: WHO. http://whqlibdoc.who.int/publications/2005/9241593229_eng.pdf

Number of community-based family planning providers trained

Definition:

“Community-based family planning provider” refers to any type of individual not facility-based who provides family planning (FP) services such as counseling, distribution of methods, and referrals.  Training can refer to any type of FP training event, regardless of its duration or location.  It involves a trainee getting a thorough understanding of the essential knowledge required to perform the job and progressing from either lacking skills or having minimal skills to being proficient.

Data Requirements:

Number of people trained (based on an actual list of names for potential verification purposes), their professional positions or community affiliation (e.g. nurse-midwife, religious leader, youth group member), sex, and training topic.

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Data Sources:

Records, usually kept by the training organizer or training organization, which may be used both for administrative and monitoring purposes at a later date

Purpose:

One way to increase access to FP at the community level is to train community-based providers in FP. By gathering data on number of community-based FP providers trained, it presents a measure of how many community-based FP providers are active in a given program or area, which is an indication of how robust a FP program is at the community level.

Issue(s):

Counting “number trained” alone does not capture knowledge.  It is important that this indicator is complimented with an indicator that assesses competency or mastery of knowledge and/or skills.  An example would be, Number of community-based family planning providers trained who have mastered relevant knowledge.

References:

The ACQUIRE Project/Engenderhealth.  Programming for Training:A Resource Package for Trainers, Program Managers, and Supervisors of Reproductive Health and Family Planning Programs. 2008.

Percent of population living within two hours travel time from service delivery points providing family planning services

Definition:

A service delivery point is a source of family planning (FP) methods offering at least condoms and pills.  The location of the source can either be in a facility or in the community (including a community-based distributor).  

This indicator is calculated as: 

(Number of individuals living within two hours travel  time from service delivery point providing FP services / total number of individuals residing in the target area) x 100

Data Requirements:

Location of service delivery points; information on availability of FP services at those sites; population size of area surveyed

Data Sources:

Mapping of service delivery points; health information records of services provided; census data (or other sources to get estimates of population size); population-based survey; local knowledge of common modes of transportation

Purpose:

This indicator measures geographical access to FP services. Use of FP largely depends on access to FP services, which includes physical and time barriers, among other factors.  Research has shown that the more inaccessible an FP service is, the less it is demanded and used.  This indicator will not be useful in the day-to-day monitoring of program implementation (performance). However, it can highlight equity/access issues when accessed occasionally, particularly in instances when a project is working to improve health infrastructure or increase FP access through community-based distribution or other mechanisms.

Alternatively proposed indicators include:

Issue(s):

Proximity to a service delivery point that offers an insufficient and/or unreliable range of services and/or methods does not constitute access in the manner intended by this indicator.  Also, “travel time” can be a subjective - and fluctuating - measure.  For instance, a hypothetical service delivery point providing contraceptives may be about a one hour walk away in the dry season, but during the wet season, the travel time may be more than double, thus providing an inaccurate assessment of how far away a population actually is from the service delivery point of interest.

References:

Bertrand, J.T., R. Magnani, and J. Knowles. 1994. Handbook of Indicators for Family Planning Program Evaluation. The Evaluation Project.  University of North Carolina, Chapel Hill: Carolina Population Center.

USAID. 2008. Flexible Fund Guidance for Grantees: Implementation Plan (IP) and Baseline Assessments. Washington DC: USAID.

Percent of respondents who report discussing family planning with a health or family planning worker or promoter in the past 12 months

Definition:

“Health or family planning worker or promoter” will be context-specific.  But generally, this can be broadly defined as an individual who promotes family planning (FP) use or provides FP services or information, which includes both community and facility-based providers.  Discussion of FP must be limited to the past 12 months.

This indicator is calculated as:

(Number of respondents who discussed FP with a health or FP worker/promoter in the past 12 months / total number of respondents) x 100 

Data Requirements:

Verification of the number of respondents who report having discussed FP with a health of FP worker in the past year.  It is helpful if the data includes age of respondent disaggregated by age group (e.g. 15-19, 20-24, 25-29, etc.); sex; current marital status (e.g. married, cohabitating, other); type of worker/promoter (e.g. community-based distributor, health professional, health educator, etc.); and possibly age of last born child if the respondent is a parent

Data Sources:

Population-based survey; facility records or program records from community-based providers

Purpose:

This indicator assesses contact with an FP promoter or service provider and is therefore one measurement of access to FP-related information and services.  For postpartum FP programs, this indicator is particularly relevant because of the emphasis placed on “no missed opportunity” with regard to FP counseling, education, and services.  

If the indicator is disaggregated by community-based versus facility-based provider, it could help estimate the level of community-based program activity, outreach, and utilization in an area and/or trends over time.

Issue(s):

The indicator does not assess the exact topics discussed between the respondent and the worker/promoter nor does it gather information about whether an FP method was accepted or not.

References:

USAID. 2008. Flexible Fund Guidance for Grantees: Implementation Plan (IP) and Baseline Assessments. Washington DC: USAID.

Percent of women using a modern family planning method who obtained their current method from a community-based worker

Definition:

A “community-based provider” is a health worker or promoter not based at a traditional health facility; sometimes they are referred to as “fieldworkers.”  Community-based distribution of family planning (FP) methods is generally through a local store or commercial site or an individual provider at a non-commercial site, as well as other variations that are community-based.  As measured in this indicator, a woman who is using modern contraception who purchased or was given her current FP method from a community-based provider is included, but this indicator does not include a woman who only talks with the community-based provider about FP. 

Modern FP methods obtained from a community-based provider include hormonal pills, injectables, male and female condoms, and foam/jelly. Traditional or ‘non-modern’ methods include periodic abstinence, withdrawal and folk methods. 

This indicator is calculated as: 

(Number of women respondents using a modern FP method who obtained their current method from a community-based provider / total number of women respondents using a modern FP method) x 100

Data Requirements:

Current FP use; type of FP method; evaluators may also want to disaggregate data by age group (e.g. 15-19, 20-24, 25-29, etc.) and/or marital status (e.g. married, cohabitating, other)

Data Sources:

Population-based survey or project record

Purpose:

The goal of using community-based providers is to increase contraceptive use by increasing access and raising demand through information, education, and communication activities.  Community volunteers are often recruited to be community-based providers, making these kinds of initiatives particularly effective in rural and isolated communities where demand is limited and access to modern FP methods is low.  In Ethiopia, Pathfinder International has trained hundreds of market vendors to provide reproductive health/FP information, condoms, and pills to provide access to people in extremely remote areas and among semi-nomadic groups, who travel regularly to the market, thus removing transportation barriers.  Men and youth have also been greatly served since accessing services and supplies through a community-based worker is less conspicuous than going to the clinic, a concern for both groups (Burket, 2006). 

Broadly, this indicator measures how much of a role community-based providers play in providing access to FP methods.  Specifically, it measures how well community-based distribution of contraception provides coverage of FP services to a given area.

Issue(s):

The indicator does not assess where a woman may have obtained previous FP methods or what her intention is for obtaining future FP methods.  It also does not indicate if the woman received FP counseling when she obtained her method from the community-based provider.

References:

MEASURE Evaluation, USAID. 2007. A Guide for Monitoring and Evaluating Population-Health-Environment Programs. Washington DC: USAID. 

Burket, M. 2006.  Improving Reproductive Health through Community-Based Services: 25 Years of Pathfinder International Experience. Watertown, MA: Pathfinder International.

Percent of community-based family planning providers who report not experiencing a stock-out in the past 6 months

Definition:

Proportion of community-based family planning (FP) workers who report not experiencing a stockout of any FP commodities in the past six months.  A stockout is deemed to occur when a community-based provider has no supplies of a particular method, even though there may be supplies of other brands for the same method.

This indicator is calculated as:

(Number of community-based FP providers who report no stock-out in the past six months / total number of community-based FP providers surveyed) x 100

Data Requirements:

Statistics on which FP methods stocked-out by community-based provider and when the stockouts occurred

Data Sources:

Facility records or program records from community-based providers

Purpose:

This indicator provides a measure of the extent to which community-based providers have been able to serve clients with FP methods during the past year due to adequate supplies.  It also measures how well the contraceptive supply system is working, which includes good record-keeping and making correct estimates regarding demand and use.

Issue(s):

If community-based providers are not closely monitoring their FP supply, the stockout count may be inaccurate due to under-reporting.  Also, caution should be used in interpreting this indicator since FP workers can avoid stockouts by rationing supplies.

References:

Bertrand, J.T., R. Magnani, and J. Knowles. 1994. Handbook of Indicators for Family Planning Program Evaluation. The Evaluation Project.  University of North Carolina, Chapel Hill: Carolina Population Center. 

USAID. 2008. Flexible Fund Guidance for Grantees: Implementation Plan (IP) and Baseline Assessments. Washington DC: USAID.

Number/percent of FP clients reached by a community-based worker in the past 12 months

Definition:

A “community-based worker” is a health worker or promoter not based at a traditional health facility, though may be linked to a traditional health facility. They are sometimes referred to as “fieldworkers” or “outreach” workers. Community-based distribution of family planning (FP) methods is generally through an individual provider, local store, or commercial site, as well as other variations that are context specific. This indicator includes men and women who are new or current family planning clients that had a formal interaction with a community-based worker in the prior 12 months. The term “reached by” refers to formal interactions that may include counseling, commodity provision, FP service provision, or other formal interactions for the purposes of FP.

The indicator can be modified to fit program needs. Possible modifications include the adjustment of the time period (past six months, past three months) and refinement of “FP client” to only include clients receiving services related to modern FP methodss. Modern FP methods obtained from a community-based provider include hormonal pills, injectables, male and female condoms, and foam/jelly. Traditional or ‘non-modern’ methods include periodic abstinence, withdrawal and folk methods. 

This indicator is most often reported as a count. If the data are available, the percentage can be calculated as: 

(Number of male and female FP clients who were reached by a community-based worker in the past 12 months / total number of male and female FP clients ) x 100

Data Requirements:

Number of FP clients reached by community-based workers. If desired: type of FP method; total number of FP clients (facility-based + community outreach). Evaluators may also want to disaggregate data by age group (e.g. 15-19, 20-24, 25-29, etc.) and/or marital status (e.g. married, cohabitating, other)

Data Sources:

Community-health worker records.

Facility-based records recording activities of community-health workers.

The indicator can be used to assess coverage of community-based distribution through the use of a population-based survey. In such a case the indicator could be modified to be “Percent of current FP users who received their method from a community-based worker in the past 12 months”.

Purpose:

The goal of using community-based providers is to increase contraceptive use by increasing access and raising demand through information, education, and communication activities.  Women are increasingly able to access their method of choice from community health workers, so it’s important to have some measure of their reach (Scott et all, 2015). Quite often community-based workers are associated with a health facility and provide services for the catchment area of the facility. Community volunteers are often recruited to be community-based providers, making these kinds of initiatives particularly effective in rural and isolated communities where demand is limited and access to modern FP methods is low. 

Broadly, this indicator measures how much of a role community-based providers play in providing access to FP methods. Specifically, it measures how a particular population of FP users is being reached with community-based services.

Issue(s):

The indicator does not assess the quality of the interaction between the community-based worker and the FP user. It does not measure what specific activities occurred during the interaction, namely commodity distribution, education, or referral for services.  There may be issues of data quality at a facility or in community-health workers’ records that could lead to double counting and inaccuracies that are difficult to verify.

References:

Population-Health-Environment Programs. Washington DC: USAID. 

Scott V, Gottschalk L, Wright K, Twose C, Bohren M, Schmitt M, Ortayli N, 2015. Community Health Workers’ Provision of Family Planning Services in Low- and Middle-Income Countries: a systematic review of effectiveness. Studies in Family Planning. 46(3); 241-261.

Number/Percent of community health workers certified to inject contraception

Definition:

Of those community health workers (CHWs) trained, the number who passed a post-training practicum and became certified to offer injectable contraception.

As a percent this indicator is calculated as:

(Number of CHWs certified to inject contraception / Number of CHWs trained in providing injectable contraception) x 100

Criteria for passing a post-test will vary by program/country, but should include questions to ensure CHWs can properly screen for initiation of injectable contraception and can identify conditions that would require discontinuation. In most cases, only those who pass the written test should be eligible to take the practicum. The numerator can then be the number passing the practicum and the denominator the total number trained. 

Data Requirements:

Number of CHWs trained and the results of their practicum assessment

Data Sources:

Program training records

Purpose:

Program managers should use this indicator to determine that the number of CHWs certified to inject contraception is sufficient to meet project goals. In addition, most of those trained should be officially certified within the program's regular certification time frame and process.

References:

FHI 360. Guidance for Monitoring and Evaluation of Community-Based Access to Injectable Contraception. Durham, NC: FHI 360; 2018. Retrieved from https://www.fhi360.org/sites/default/files/media/documents/guidance-injectable-contraceptives.pdf 

Number/Percent of community health workers certified during the previous reporting period who received at least one in-person supportive supervision visit for providing injectable contraception within [x] months after successful completion of practicum

Definition:

Of the community health workers (CHWs) who were certified during the previous reporting period, the number who received at least one in-person supportive supervision visit for providing injectable contraception within a given time frame after completing a practicum.

The appropriate length of time after training is to be defined by in-country standards.

Supervision should include both counseling and injection skills, cover reiterative skills, and address gaps.

As a percent, this indicator is calculated as:

(Number of CHWs certified during the previous reporting period who received at least one in-person supportive supervision visit for providing injectable contraception /  Number of CHWs certified to provide injectable contraception) x 100 

Data Requirements:

Number of CHWs certified during the previous reporting period; log of in-person supportive supervision visits

Data Sources:

Program training records with number of CHWs certified during the previous reporting period; records of in-person supervisory visits

Purpose:

Supervisory visits play an extremely important role in monitoring the safety and effectiveness of community-based access to injectable contraception programs. Although programs may vary in the intervals of supervisory visits, the recommendation is at least one visit per month in the first few months immediately following certification. After a CHW has proven to provide high-quality injectable services, the visits may be reduced to every quarter, which can be incorporated into existing processes.

Issue(s):

This indicator does not measure the quality nor the outcome of the supervisory visit.

References:

 FHI 360. Guidance for Monitoring and Evaluation of Community-Based Access to Injectable Contraception. Durham, NC: FHI 360; 2018. Retrieved from https://www.fhi360.org/sites/default/files/media/documents/guidance-injectable-contraceptives.pdf

Number/Percent of community health workers reporting a stock-out of injectables

Definition:

Number of community health workers (CHWs) within the authorized cadre who reported having an inadequate supply of injectable contraception.

As a percent, this indicator is calculated as:

(Number of CHWs reporting a stock-out of injectable contraception /  Number of CHWs certified in providing injectable contraception who have given an injection in the last quarter) x 100

Data Requirements:

Verification of stockout of injectable contraception

Programs may wish to further disaggregate by other needed materials such as alcohol swabs or bandages.

Data Sources:

CHW reports

Purpose:

Just as programs need to ensure that enough CHWs are available, the workers must also have sufficient stocks of injectables to meet demand. Ideally, stock-outs should be rare or nonexistent, and any reports of regular stock-outs should be investigated immediately.

References:

FHI 360. Guidance for Monitoring and Evaluation of Community-Based Access to Injectable Contraception. Durham, NC: FHI 360; 2018. Retrieved from https://www.fhi360.org/sites/default/files/media/documents/guidance-injectable-contraceptives.pdf

Number of injections provided

Definition:

Number of injections provided by a community health worker (CHW) to any type of client (new users or those receiving a resupply) during the reporting period. 

Data Requirements:

Number of injectables provided during reference period and the profile of family planning (FP) clients receiving injections.

Disaggregate by number of clients new to FP (first FP use ever; number of clients new to the method, but had previously used FP; number of resupply injections; and number of on-time injections (within grace period).

Data Sources:

CHW client data reports

Purpose:

At a minimum, knowing the number of injections provided by CHWs can help program managers understand whether they have created enough demand for community-based access to injectable contraception services. Tracking the number of injections provided compared with program targets and past trends helps program managers identify concerns early.

Issue(s):

This indicator does not capture the quality of the service delivery, such as accurate counselling provided to the FP client by the CHW, accidental needle sticks, or infections or abscesses at the site of the injection.

References:

FHI 360. Guidance for Monitoring and Evaluation of Community-Based Access to Injectable Contraception. Durham, NC: FHI 360; 2018. Retrieved from https://www.fhi360.org/sites/default/files/media/documents/guidance-injectable-contraceptives.pdf