Improving Uptake of Family Planning Services in Western Kenya: Evaluation Findings and Key Learnings

Improving Uptake of Family Planning Services in Western Kenya: Evaluation Findings and Key Learnings Clair Null With support from the David and Lucile Packard Foundation, the “Reversing the Anitha Sivasankaran Stall in Fertility Decline in Western Kenya” project was launched in 2009 to counter Kimberly Smith stagnating and deteriorating reproductive health indicators in western Kenya. Imple- mented by a consortium of partners, this six-year initiative, which became known as the Packard Western Kenya (PWK) project, aimed to strengthen the supply of and generate demand for family planning services—and ultimately reduce unmet need for contraception and fertility rates—with a focus on long-acting and permanent methods (LAPM) and sustainability. This brief summarizes key findings from a mixed-methods evaluation of the PWK project. The PWK Project Consortium Challenged by an alarmingly high population to 4.7 by the 1990s. Community-based distribution • The African Population and growth rate at independence, Kenya became an (CBD) of contraceptives, funded primarily by donors, Health Research Center early leader on family planning (FP) by making it an is often credited with the concurrent and equally (APHRC) coordinated all essential component of the country’s development dramatic increases in the modern contraceptive project activities. strategy. Adopting its first national population policy prevalence rate (CPR). However, as donor atten- • Marie Stopes Kenya (MSK) and FP program in 1967, Kenya went on to have a tion and funding shifted to HIV/AIDS, funds for FP and Family Health Options strong and successful FP program in the 1980s and declined, compromising gains in FP service provision Kenya (FHOK) implemented project activities in Busia 1990s, resulting in a dramatic decline in the fertility and contraceptive use and leading to a prolonged and Siaya Counties, respec- rate—from 8.1 children per woman in the 1970s stall (and reversal in some areas) in fertility decline. tively. • Great Lakes University of Kisumu (GLUK) conducted monitoring of project activities. PWK Project at a Glance During the expansion phase (2012-2015), the project Objective 1: Improve the supply of FP services also coordinated with other • Community Health Volunteers (CHVs) are recruited and trained to provide quality family planning Packard Foundation grantees (FP) information and counseling, and to distribute pills and condoms targeting specific subpopula- tions, including: • Facility staff are trained to deliver long acting and reversible contraceptive (LARC) methods and reduce contraceptive stock-outs through improved commodity management (the project pro- • Center for the Study of Ado- vided emergency buffer stocks) lescence (CSA) • Mobile outreaches are organized to bring a full range of FP methods, including long-acting and • Forum for African Women permanent methods (LAPM), closer to rural communities Educationalists (FAWE) • Christian Health Association Objective 2: Generate demand for FP services of Kenya (CHAK) • CHVs conduct household visits and community sensitization meetings and distribute information, Consortium members also education, and communication (IEC) materials worked closely with the Minis- try of Health in both counties. • CHVs provide referrals to facilities for reproductive health and FP services requiring medical intervention Objective 3: Create an enabling environment for FP • Project activities are monitored and project achievements and lessons learned are disseminated • PWK partners engage with county government officials and other partners in dialogue on FP issues • Advocacy acitivities promote county budget allocations to support FP and sustainability of project June 2016 In light of these trends, the Kenyan government EVALUATION OVERVIEW tried to reposition FP as a development priority, making the National Coordinating Agency for The evaluation assessed the implementation, out- Population and Development (NCAPD) a semiau- comes, and sustainability of the PWK project. It also sought to identify key lessons learned and recom- Evaluation Goals tonomous agency within the Ministry of Planning and National Development in 2004. It also added mendations for future FP programming in Kenya. The 1. Document project imple- a new line item for FP commodities to the 2005 study relied primarily on the collection and analysis of mentation Ministry of Health (MoH) budget, launched a in-depth qualitative data, triangulated with program 2. Assess the project’s influ- National Reproductive Health Strategy in 2007, monitoring and other secondary data. Qualitative data ence on FP knowledge, and developed a Strategy for Improving Uptake of from female youth (ages 15-24), women (ages 25-49), attitudes, and practices LAPM in 2008. During this period, the government men (ages 18-59), and CHVs were collected through 3. Provide insights into key also launched the Community Health Strategy focus group discussions (FGDs). In-depth interviews factors affecting the sus- (2006), which sought to improve access to and use (IDIs), sometimes in groups, were conducted with tainability of the project of health services, including FP, at the community CHEWs and health facility staff. Among these respon- 4. Identify key learnings and level. The strategy organized Community Health dent types, 64 FGDs and 30 IDIs were conducted recommendations for Volunteers (CHVs) into Community Units, linked across 16 facility catchment areas (8 in Busia and 8 in future FP programming in Kenya to a health facility and supervised by Community Siaya). IDIs were also conducted with 8 county and Health Extension Workers (CHEWs). In doing so, 6 national level stakeholders, and 7 project staff, for a it began phasing out the parallel CBD system that combined total of 114 FGDs and IDIs. relied on CBD agents. KEY FINDINGS: IMPLEMENTATION Against this backdrop, the PWK project was developed in 2009 as part of a larger national effort by In collaboration with the MoH, the project the Kenyan government, donors, and NGOs to recruited and trained a new workforce of 600 counter the stall in fertility decline in Kenya. The CHVs integrated into MoH structures to deliver PWK project, initially launched as a three-year FP services at the community level. To support demonstration project (2009-2012), is a communi- “Some of us although we rapid scale-up and sustainability, the project lever- used to be health workers ty-based FP initiative implemented in two large rural before we were trained by aged existing CHVs and recruited new CHVs through counties in western Kenya: Busia and Siaya. These Packard, there were some local governance structures. CHVs were trained on counties were selected because of their high fertil- areas where we were still shy. the MoH’s CHV curriculum by MoH trainers, using So Packard really enlightened ity rates and low CPR in 2009 and the absence of us and helped us to be coura- the basic and FP-specific modules for new CHVs donor or other FP initiatives. From 2012-2015, proj- geous and to talk about reality and the FP module for existing CHVs. CHVs demon- ect activities were intensified and scaled up in Busia concerning sex. .” strated a strong understanding of the project’s goals, - CHV and Siaya during the project’s expansion phase. and felt the training equipped them with the knowl- PWK project goals were to (1) increase routine use edge and confidence needed to deliver FP infor- of contraceptives among women of reproduc- mation, counseling, and commodities. Many CHVs tive age and (2) reduce preferred family size and became passionate champions for FP, speaking influence fertility intentions among women and openly about their own experiences with LAPM and men. The project adopted an integrated, sus- other methods. CHVs felt supported by CHEWs and tainable model of FP service provision that aligns facility staff, reporting that they generally received with the existing policy priorities and systems necessary commodities and guidance. mentioned above, and addresses both demand- Over 160 providers were trained on delivery of LARC and supply-side barriers to increase uptake of FP methods, with some facility staff receiving training services. The project has three key components: on commodity management. A seven-day training “We had been offering shal- (1) improving the supply of FP services by training low counseling on FP at the on provision of long-acting reversible contraception CHVs to provide CBD services, conducting mobile facility, so after that training (LARC) was offered to facility in-charges and other outreaches, and training facility staff, (2) increas- I learned how to counsel a providers identified by the county Reproductive Health mother properly.” ing demand for FP services through household Coordinator. Providers praised the comprehensiveness - Facility staff visits, community meetings, and distribution of and quality of the training, believing it improved their information, education, and communication (IEC) ability to provide counseling on FP methods, while materials, and (3) improving the policy environ- also allowing them to provide new contraceptive ment through advocacy to promote budget methods, specifically implants and intrauterine contra- allocations for FP and sustainability of the project’s ceptive devices (IUCDs). Facility staff also appreciated interventions. the commodity management training, though implementation of this training was more limited. 2 Mobile outreaches were a key vehicle for in outreaches in Siaya, resulting in high

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