Page 1

November 2008

KENYA COMPARATIVE

ASSESSMENT OF

LONG-ACTING &

PERMANENT METHODS

ACTIVITIES

Final Report

Version 1.2 September 30, 2008

Kenya Comparative Assessment of LAPM Activities: Final Report

DRAFT v1.2, September 30, 2008

Executive Summary .......................................................................................................... 3

Introduction..................................................................................................................... 10

Recent Kenyan interventions for LAPM and IUCD ............................................... 10

National efforts........................................................................................................ 11

AMKENI Project .................................................................................................... 11

AMUA Social Franchise Project............................................................................ 13

ACQUIRE Project: Kisii FP Revitalization Initiative......................................... 13

Objectives and methods.................................................................................................. 14

Objectives..................................................................................................................... 14

Methods........................................................................................................................ 15

Results of the interventions: LAPM uptake ................................................................. 16

Short-term reactions to intervention activities......................................................... 19

General sustainability of the interventions............................................................... 21

Intervention design ..................................................................................................... 21

Ensuring an adequate supply of trained personnel ..................................................... 21

Provider training experiences.................................................................................... 22

Availability of LAPM services ................................................................................... 23

Training of private sector providers ......................................................................... 23

Maintaining a trained workforce .............................................................................. 24

Provider behavior and attitudes................................................................................ 24

Provider biases remain, particularly about the IUCD ............................................ 25

Facility and provider incentives ................................................................................ 26

Making commodities, equipment and expendable supplies available ....................... 27

Commodities, equipment and expendable supplies remain a problem ................. 28

Improving knowledge and confronting myths to help create demand ...................... 29

Community-based distribution agents and peer educators .................................... 29

Media campaigns ........................................................................................................ 30

Client post-intervention knowledge and attitudes ................................................... 32

Male involvement ........................................................................................................ 33

Pricing of commodities and client incentives............................................................ 34

Promising directions for future LAPM interventions ................................................. 34

Latent demand for TL ................................................................................................ 35

Conclusion ....................................................................................................................... 35

Appendix: Documents Reviewed ................................................................................... 39

Kenya Ministry of Health, LAPM Comparative Assessment

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Acknowledgements

Family Health International (FHI) and the Ministry of Health (MOH) would like to thank

the following organizations and individuals for their contribution in ensuring the

successful completion of the LAPM Comparative Assessment.

We especially thank Dr. Josephine Kibaru; Head of the Division of Reproductive Health

(DRH), Ministry of Health who agreed to collaborate with FHI, ACQUIRE Project and

AMUA Project and allowed DRH staff to fully participate in the study. Dr. Bartilol

Kigen, Programme Manager for the Family Planning and HIV/AIDS programme was

instrumental in guiding the study team and further ensured access to the study sites and

final review of the report. In addition, we thank Mary Gathitu and Cosmas Mutunga, both

of the Division of Reproductive Health (DRH), who introduced the study team to the

respective districts where the study took place and participated in training of Research

Assistants. We further acknowledge the crucial role played by the DRH, during the

dissemination workshop.

We are also grateful to the Provincial Medical Officer of Western Province, Dr. Olang’o

Onudi for ensuring that the research team was able to conduct field activities smoothly.

Consistent communication with providers from the study sites would have not been

possible without the help of Dr. Janet Wasiche in Western Province and Dr. Benedict

Osore in Rift Valley Province as well as Jane Maina, Rift Valley Project Coordinator of

AMUA Project.

This study would not have been possible without the involvement of the AMUA,

ACQUIRE and former AMKENI project. We particularly thank Mr. Cyprian Awiti,

Ferdinard Mose, Walter Odhiambo and George Obhai of AMUA, Dr. John Pile and Dr

Fredrick Ndede of ACQUIRE Project; and Feddis Mumba of Engenderhealth, Maureen

Kuyoh, Rick Homan, Erin McGinn, Dr. Jennifer Wesson, Dr. Marsden Solomon, Violet

Bukusi of FHI, who were actively involved in either the design of the assessment study,

support during its implementation or review of the final report. We also would like to

thank Caroline Njue, FHI consultant, who worked tirelessly on key informant interviews

and training of research assistants.

The following research assistants ensured quality data collection during the survey:

Wycliffe Kokonya

Matthews Ogutu

Florence Khakame

Peter Wafula Khaemba

Kweyu Nicholus Lumbasi

Jackline Kivunaga

Samuel Kedogo

Yvonne Amboko

Julius Munyao

Eva Muema

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

Enoch Matte

Beatrice Wangari

Martin J.L. Simiyu

Rosemary Wangui

David Odhiambo Otieno

Getrude A. Akinyi

This assessment was made possible through support provided by USAID under the terms

of Co-operative Agreement No. GPO-A-00-05-00022-00. The opinion expressed here in

are those of the authors and do not necessarily reflect the views of USAID.

Photo credits: Ferdinand Mose and Fredrick Ndede.

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

Contributors

This comparative assessment was a joint exercise under the auspices of the Ministry of

Health, Division of Reproductive Health. Along with MOH personnel, staff members

from Family Health International, EngenderHealth, and AMUA Project contributed data,

time and input into the conduct of the assessment and the writing of this report.

Contributors included:

Dr Josephine Kibaru

Dr Bartilol Kigen

Jennifer Wesson

Erin McGinn

John Pile

Ferdinand Mose

Violet Bukusi

Marsden Solomon

Frederick Ndede

Feddis Mumba

Kenya Ministry of Health, LAPM Comparative Assessment

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Executive Summary

Introduction

In 1989, long-acting and permanent methods of contraception (LAPMs) accounted for 47

percent of all modern contraceptive use among currently married women aged 15-49 in

Kenya. In 2003, the LAPM share of modern contraceptive use had decreased by 55

percent to 21 percent of modern contraceptive use in Kenya. In the past five years,

efforts have been made to ensure a range of contraceptive choice in Kenya. The most

comprehensive interventions have occurred under the leadership of the Ministry of

Health’s IUCD Reintroduction Task Force, which helped launch several interventions

with the goal of increasing use of IUCDs and, by extension, long-acting and permanent

methods of contraception (LAPMs). Three recent projects have embraced models

incorporating LAPM advocacy, stable supply, and demand creation: AMKENI, AMUA,

and ACQUIRE. All of these projects have similar end points (i.e., increase in LAPM

use), which affords a unique opportunity to examine more closely the medium-term

outcomes and impact of each intervention, and to determine which combination of these

approaches might be best for increasing LAPM use.

This assessment employs a multiple-case study (comparative) approach in which each of

these three major LAPM-related interventions was defined as a “case.” We use pre-

existing project information and data collected specifically for this purpose; the primary

data used to compare the interventions were the pre- and post-intervention levels of

LAPM provision at the service delivery sites. In addition, program managers, providers,

and clients were interviewed in April and May 2007 at all the sites included in the study.

The ultimate goal of this assessment is to inform the design of future LAPM

revitalization efforts in Kenya.

Results of the interventions: LAPM uptake

Direct comparisons among the interventions are difficult because of their differing

objectives and sizes; however, all three targeted the IUCD. This assessment examines a

small, comparable number of sites for each intervention. The table below demonstrates

that while percentage increases in IUCD uptake were impressively high at the peak of

each intervention, the maximum monthly provision of IUCDs was still relatively low. At

their peak, a sample of AMKENI sites provided approximately eight IUCDs per site per

month. A sample of AMUA sites

provided a high of five IUCDs

per site per month. The six-

month-period high for the

ACQUIRE sites was 12 IUCDs

provided per site per month.

Comparison of peak IUCD uptake among intervention sites

% Increase in

IUCD uptake at

peak

Average number IUCDs

per site per month at

intervention’s peak

AMKENI*

1187%

8

AMUA±

160%

5

ACQUIRE**

734%

12

*AMKENI peak quarter Q3 2004, 193 IUCDs in 8 sites; ± AMUA peak, Q4 2006,

143 IUCDs in 10 sites; **ACQUIRE peak Q1 2007, 484 IUCDs in 13 sites.

Beyond the IUCD, all the projects increased provision of other LAPMs, but few of these

increases were sustained beyond the end of the project. AMKENI concluded in March

2006, at which time the eight sites included in this assessment were providing between

four and five times the numbers of IUCDs, implants, and tubal ligations (i.e., tubal

ligations [TL] = female sterilization) compared to baseline, although these increases were

Kenya Ministry of Health, LAPM Comparative Assessment

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smaller than the provision the project achieved at its peak. A sample of 10 clinics

participating in either the AMUA network or mobile TL services nearly tripled provision

of IUCDs and TL from January - June 2005 to January - June 2007. The AMUA project

is on-going. Although the ACQUIRE project specifically targeted IUCDs, the district it

worked in also experienced a five-percent increase in all family planning (FP) clients, and

a 19-percent increase in uptake of female sterilization. As with IUCD provision, the

actual numbers of clients using these LAPMs were small, despite the dramatic percentage

increases, ranging from less than one client per clinic per month at baseline to a

maximum of 12 clients per clinic per month.

This comparative assessment was able to address longer-term sustainability for two of the

three interventions (the AMUA project is ongoing). Review of LAPM uptake in sites

from the AMKENI intervention, which ended in March 2006, raises some concerns

regarding sustainability. Fifteen months after AMKENI’s conclusion, the number of

IUCDs and implants provided remained elevated. This increase was observed in a

selection of high- and low-performing AMKENI facilities, which may approximate an

average level of achievement for AMKENI facilities. On the other hand, provision of TL

quickly returned to baseline levels after the conclusion of the AMKENI project. In

another positive finding, despite a large decrease in IUCDs provided during a district

staff transfer in Kisii, the provision of IUCDs in ACQUIRE pilot sites remains elevated

over one year after the intervention concluded, and indeed continues to grow.

Intervention elements and lessons learned

Ensuring an adequate supply of trained personnel

• Maintaining a trained workforce in facilities after interventions end is an ongoing

issue. Respondents reported frequent transfers of trained providers to other duties

where they no longer use the skills they acquired through the interventions.

• Past research demonstrated that not only provider skills, but also provider attitudes

constitute a barrier to LAPM use. Attitudes may affect how providers counsel about

LAPM. A large majority of providers in AMKENI and AMUA facilities said that

they always counsel clients about IUCDs, implants, and TL. However, there is a gap

between what providers say about their counseling, and what clients report providers

tell them. Among the few clients interviewed who were coming to the facility for a

new method, less than half said that the provider discussed the IUCD, TL, or

vasectomy with them.

• Despite large numbers of provider trainings, provider biases against certain methods

(notably the IUCD) remain. Some providers expressed unfounded concerns about the

relationship between IUCD and pelvic infection, and there was some evidence among

both providers and clients in former AMKENI and AMUA sites that the IUCD is

perceived as ineffective at preventing pregnancy.

Making commodities, equipment, and expendable supplies available

• All of the ACQUIRE-supported facilities were fully equipped for IUCD insertion and

removal when they were observed six months after the end of the ACQUIRE

intervention. A year after AMKENI ended only 20 percent of AMKENI facilities

were fully equipped for IUCD insertion and removal, while the AMUA project

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Version 1.2 September 30, 2008

(ongoing) has only 70 percent of its facilities equipped for IUCD insertion and

removal. Only 10 percent and 20 percent of facilities respectively were equipped for

implant insertion and removal at the time of facility audits.

• Ensuring adequate commodities and other consumable supplies for LAPMs (and

other FP methods) is a constant challenge. Implants were stocked out nationally at

least twice during the past seven years, and injectable contraceptives were out of

stock during the time of fieldwork for the assessment. Among 22 AMKENI and

ACQUIRE facilities examined, only two had DMPA in stock. Stock-outs can force

clients to choose methods they may not originally prefer. Data from Kisii showed

IUCD uptake increased when there were DMPA stock-outs. Several of the LAPM

users interviewed said that they had been compelled to select another, less appealing

alternative due to injectable stock-outs.

Improving knowledge and confronting myths and misconceptions to help create demand

• All three interventions included either community based distribution (CBD) agents or

volunteer peer educators in their demand creation activities. Providers in all

interventions agreed that CBD agents and peer educators had improved community

opinions about LAPM. Both providers and clients suggested that one of the best ways

to improve clients’ views about specific methods was by using peer education,

particularly by satisfied users of that method. CBD agents seemed to play a role in

education and referral to clinics, but retaining committed volunteers over time is

challenging.

• The ACQUIRE communications campaign was designed to address women’s and

men’s views about the IUCD and to challenge myths and rumors. Using the slogan,

“Now you know the truth,” the campaign’s goal was to improve the image of the

IUCD in the community. An evaluation of this campaign in April 2007 showed that

45 percent of the district reported hearing or seeing IUCD advertising in the past six

months. Nearly one in five respondents had attended a community session focused

on the IUCD. Once those sessions concluded, respondents were likely to take some

action about family planning, such as talking to a partner or family/friend. The

ACQUIRE project concluded that while advertising encourages method awareness

and consideration, community sessions are integral to driving people to action.

• Given the relatively greater achievement of IUCD provision in ACQUIRE, it appears

that targeted messages were more effective than the broader information, education,

and communication (IEC) messages of AMKENI and AMUA.

• Despite community outreach and mass media campaign efforts, knowledge about

LAPMs was still somewhat low among family planning clients attending AMKENI

and AMUA facilities (between 22 and 52 percent of clients said they did not know

about each LAPM method). Among the clients interviewed, relatively large

proportions of respondents reported that their knowledge about LAPM methods was

insufficient to make a judgment about them.

Client perspectives on LAPMs

• Understanding the motivations of LAPM clients may help to better promote these

methods in the future. For LAPM users, the long-acting effectiveness or permanence

of the methods is an important advantage. Some users emphasized the convenience

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

of not having to make repeated trips to the clinic. Other users said they preferred

long-acting methods because they do not have to remember to take pills every day, or

remember to come back for re-injections. Some users noted the lower costs associated

with using a long-acting method.

• While overall use of TL has declined in Kenya, many providers interviewed noted

that TL demand was not only strong, but increasing in their facilities. Current LAPM

clients seemed to have a good impression of female sterilization overall, and many

indicated that it would be their preferred method of contraception once they had a

desired number of children. Despite the demand for TL, interventions have faced

challenges in increasing access to permanent methods of contraception. Only about

20 percent and 12 percent of providers interviewed for this assessment had received

any TL or vasectomy training, respectively, in the past five years. Among the

facilities included in this assessment, only about half offer any permanent method of

contraception (TL and/or vasectomy).

Conclusion

The interventions that were examined lasted from two to five years and attempted to

address significant issues with health systems and entrenched attitudes among providers

and clients. Although all three projects made progress, the magnitude of progress, in

terms of the total number of clients served was relatively modest, compared to the total

number of FP clients. Longer-term outcomes were mixed. In the case of AMKENI,

cessation of project activities appears to have coincided with rapid returns to near-

baseline levels of method provision. This failure to sustain progress could be due to staff

transfers and to logistical problems with equipment, supplies, and commodities. On the

other hand, the ACQUIRE project observed continuing increases in IUCD service

provision several months after the project concluded. Still in progress, AMUA has

increased and maintained its increase of LAPM provision. Regardless of how the

intervention performed, they often had challenges with training, readiness of facilities in

terms of equipment and commodities and demand creation. One single element did not

stand out as the most important determinant of increased LAPM uptake.

The assessment reveals several important lessons. Implementing both supply-side and

demand-side activities at the same time as conducting advocacy seems to be the best

model for this kind of work. ACQUIRE, an intervention targeted at one method, seemed

to yield more positive results. The implementation of the AMUA social franchising

network of private providers may be a promising direction for future public-private

partnership efforts, if the costs can be controlled. The costs associated with targeted

IUCD or broader LAPM/FP interventions have not been examined, thus information on

cost per CYP, replicability, and sustainability is lacking. Instead of primarily relying on

donor funds, LAPM efforts should be mainstreamed into the MOH structure and funded

through the annual operating plans. Finally, if they decide that LAPM efforts should

continue to be prioritized, the MOH and donors need to take a longer term approach to

promoting LAPM utilization so that progress achieved during interventions can be

sustained over time.

Kenya Ministry of Health, LAPM Comparative Assessment

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Introduction

During the past 20 years in Kenya, the percentage of currently married women using any

modern contraceptive has tripled, from 10 percent to 33 percent.

1-4

Despite the increases

in contraceptive use, over 24 percent of currently married women aged 15-49 still have

an unmet need for family planning.

3

According to the 2003 Kenya Demographic and

Health Survey (KDHS), contraceptive prevalence has plateaued after decades of steady

growth, and Kenya’s total fertility rate has increased slightly.

3

Kenyan policy makers are concerned about how to maintain and expand reproductive

health services when national and donated resources are not meeting anticipated

commodity needs. Nearly half of Kenya’s population (13 million) is under 15 years of

age, and 100,000 young people turn 16 every year, a pattern that will continue for over a

decade. Use of long-acting methods such as the intra-uterine contraceptive device

(IUCD) and female sterilization (e.g. tubal ligation, TL) is decreasing, while a continuing

increase in the use of injectables made it the predominant method in 2003.

3

In 1989,

long-acting and permanent methods of contraception (LAPMs) accounted for 47 percent

of all modern contraceptive use among currently married women aged 15-49 in Kenya

(20.6% intrauterine contraceptive device (IUCD); 26.2% female sterilization).{#139}

Over ten years later, the LAPM share of modern contraceptive use has decreased by 55

percent. In 2003, only 21 percent of modern contraceptive use in Kenya was attributed to

LAPMs (7.6% IUCD, 13.7% female sterilization).{#139} Male sterilization has

remained almost nil in Kenya.

One concern about increasing reliance on short-acting methods is that methods like

injectables and pills have been shown to have higher rates of discontinuation within a

year than does the IUCD, a long-acting method.

5

All of these trends mean that demand

for family planning commodities will continue to increase. The declining utilization of

long-acting and permanent methods (LAPM) occurs at a time when the total annual cost

of all commodities is projected to increase from US$16.7 million in 2004 to US$21.7

million in 2015 just to maintain the current prevalence rate and method mix.

i

Recent Kenyan interventions for LAPM and IUCD

In the past five years, several efforts have been made to ensure a range of contraceptive

choice in Kenya. The most comprehensive interventions have occurred under the

leadership of the Ministry of Health’s (MOH) IUCD Reintroduction Task Force, which

helped launch several interventions with the goal of increasing use of IUCDs and, by

extension, LAPM. The MOH and other partners have also led national efforts.

i Based on a forecast done using the ACQUIRE Project Reality √ Tool. The forecast used the CPR and

method mix from the 2003 DHS, UN projections for the number of women of reproductive age 2003-2015

in Kenya, and ran a projection assuming no change in the CPR/method mix. See www.engenderhealth.org

for more information about the tool.

Kenya Ministry of Health, LAPM Comparative Assessment

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Ken

r 30, 2008

ya Ministry of Health, LAPM Comparative Assessment

11

National efforts

In 2002, the MOH, Division of Reproductive Health led a nationwide initiative to

introduce Norplant© by training providers how to insert and remove the device. The

MOH revised service provider guidelines to allow nurses and clinical officers to provide

implants. Subsequently, national provider trainings and enhanced commodity and

expendable supplies were provided. In 2004, Norplant© was phased out of the Kenyan

FP program and replaced by Jadelle and Implanon.

9

The MOH and FHI, together with professional associations (the Kenya Medical

Association, the Kenya Obstetrics and Gynecological Society, the Nursing Council of

Kenya, and the Kenya Medical Training College), carried out continuing professional

development (CPD) sessions for public and private sector health care providers in all

eight provinces, and for trainers from training institutions around Kenya in 2004 and

2005 (Table 1). The trainers (university lecturers and lecturers in private and public

medical training institutions) were targeted because of their role in molding the country’s

pool of service providers. In total, 376 public sector providers and managers, 235 private

practitioners, and 83 trainers from 39 training institutions participated.

The MOH updated the National Guidelines on Reproductive Health and Family planning

in 2005 to reflect changes in the World Health Organization (WHO) medical eligibility

criteria (MEC) for contraceptive use.{#139} These guidelines were disseminated

through the CPD sessions, among other means. The CPD sessions also provided

information on changing RH trends in Kenya. Although evaluation efforts of the sessions

were sporadic, reports showed that levels of knowledge increased approximately 15

percentage points from pre-training to post-training tests. A mail evaluation six months

after the CPDs showed that providers had retained much of that knowledge, especially

about the IUCD, but the limited information available on their IUCD provision did not

show increases (unpublished data, FHI).

Three large-scale LAPM interventions have also taken place in Kenya since 2000.

AMKENI Project

AMKENI was designed and funded by USAID/Kenya and operated under the auspices of

the MOH. The goal of this five-year RH project was to increase the provision of

sustainable, integrated, comprehensive RH/FP/child survival (CS) services, including

HIV/AIDS prevention services, at the community level. From this goal, AMKENI

formulated three objectives:

1. Increasing access to sustainable comprehensive RH/FP/CS services, including

HIV/AIDS prevention services

2. Improving the quality of sustainable, comprehensive RH/FP/CS services,

including HIV/AIDS prevention services

3. Increasing healthier behavior among the population

y of Health, LAPM Comparative Assessment

12

Version 1.1 Sep 17, 2008

Kenya Ministr

Principal sector

targeted

Activities for LAPM promotion

Provider training

Name

Coordinating

agencies

Geographic

area

Private Public

Policy/

guideline

changes

Clinical

training

Sensiti-

zation

Commodity/

supply

systems

Facility/

equipment

upgrades

CBD/Peer

Educator

involvement

Communi-

cations

campaign

Services

targeted

Budget

obligated

AMKENI

Q1 2000-

Q2 2006

EngenderHealth,

Program for

Appropriate

Technology in

Health (PATH),

FHI, IntraHealth

International

Inc.nj

96 facilities

in Coast

and

Western

provinces

X

X

X

X

Reproductive

health, all FP

methods, child

survival

US$18.9

million

MOH

Initiative to

Access

Norplant®

Q1-Q4 2002

Ministry of

Health/ Division

of Reproductive

Health

National

X

X

X

X

Norplant®

Not

available

CPD

seminars

Q1 2004-Q4

2005

FHI, Ministry of

Health/ Division

of Reproductive

Health

All 8

provinces &

national

trainers

X

X

X

All FP,

emphasis on

IUCD

US$

90,000

Amua

Network

Q2 2004-

ongoing

Marie Stopes

Kenya, Marie

Stopes

International,

MOH

141

providers in

Western,

Nyanza and

Rift Valley

provinces

X

X

X

X

X

X

X

Tubal ligation,

vasectomy,

IUCD

Euros

2.0

million

Policy/

Central

Level

Q1-Q4 2005

MOH/Division of

Reproductive

Health, FHI, and

other partners.

National

X

X

X

X

All FP,

emphasis on

IUCD

US$

50,000

ACQUIRE

Q1 2005-

Q2 2007

EngenderHealth

13 facilities

in Kisii

District,

Nyanza

province

X

X

X

X

X

IUCD

US$

650,000

Table 1: Summary of recent major IUCD/LAPM interventions in Kenya

Version 1.1 Sep 17, 2008

AMKENI worked with the national Division of Reproductive Health at provincial and

district levels. The implementation model stressed the importance of addressing the

demand and the supply sides of the equation simultaneously and comprehensively in an

integrated, coordinated manner. The AMKENI Model utilized three strategies:

1. Access and quality – improving the capacity of health facilities to provide

FP/RH/CS services, including HIV- and AIDS-related services

2. Behavior Change Communication (BCC) – working with communities to promote

FP/RH/CS healthier behaviors and demand for services

3. Sustainability – strengthening the MOH’s decentralized systems for training and

supervising reproductive health service providers

AMUA Social Franchise Project

Social franchises enable distribution of products and services by harnessing unused

capacity amongst entrepreneurs in the private sector.

10

The AMUA

ii

project is supported

by the German government through its development bank, KFW (Kreditanstalt für

Wiederaufbau). Marie Stopes Kenya (MSK) with cooperation from Marie Stopes

International London (MSI) and the MOH initiated project activities in April 2004.

AMUA seeks to contribute to the improvement of the reproductive health of poorer and

hard-to-reach women (aged above 25) in under-served areas of Kenya through increased

utilization of modern clinical family planning methods (i.e, bilateral tubal ligation via

"minilap" and IUCD). Its objectives are:

1. Increasing utilization of modern clinical family planning methods in Kenya

2. Developing/implementing social marketing procedures through training and

networking of service providers

3. Improving accessibility of quality affordable clinical services through

implementation of a reliable distribution system for supplied commodities

4. Increasing demand for long-acting clinical family planning methods and

enhancing awareness of available networked services through implementation of

a comprehensive IEC/marketing campaign

The project targeted recruitment of 70 doctors 15 clinical officers and 100 nurses for

franchising. By January 2007, only seven doctors had been recruited; the targets for

nurses and clinical officers were surpassed (111 and 33 trained, respectively). Anecdotal

evidence suggests that doctors did not see a profit motive in providing sterilization

services; this issue will be further examined by the AMUA project in their second phase.

Franchisees receive subsidized supplies and equipment, and training, and benefit from

AMUA demand creation activities.

ACQUIRE Project: Kisii FP Revitalization Initiative

In December 2004, the MOH Division of Reproductive Health requested the ACQUIRE

Project’s technical assistance and support to expand IUCD revitalization efforts to Kisii

District, in southwestern Kenya. ACQUIRE and local stakeholders applied the MOH’s

ii meaning “decide” in KiSwahili

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

national IUCD strategy (developed during the AMKENI intervention).

iii

Following a

stakeholder meeting, the MOH and ACQUIRE conducted a performance needs

assessment (PNA) in order to identify critical issues; this consisted of a data collection

exercise in 12 sites, focus group discussions, and a subsequent stakeholders’ workshop.

Following this assessment, the District MOH selected 13 sites in Kisii to be fully

supported throughout the project cycle; however other sites in the Kisii District were

supported through trainings.

Efforts were made to focus on both supply and demand side needs, while simultaneous

attention was given to local advocacy among providers, stakeholders, and community

members, and creating and linking the community and campaign components. The timing

of each individual activity was coordinated so that the supply side was strengthened and

in place before the community activities and the communications campaign were

launched. Ensuring the campaign messages were consistent throughout all components of

the project – both on the supply and demand sides – was important so that clients

received accurate messages regarding family planning and the IUCD. Sensitizing project

partners before the campaign was officially launched allowed for messages to be

consistent, thus reinforcing messages of safety and uses. Peer educators, CBD, radio, and

road show events delivered campaign messages.

Objectives and methods

As described above, the AMKENI, AMUA and ACQUIRE interventions embraced

multi-dimensional models encapsulating issues of both supply and demand.

iv

At the

same time, the interventions have had slightly differing foci. For example, the AMUA

Network works with private sector providers, while the bulk of AMKENI and ACQUIRE

work was with public sector providers. ACQUIRE concentrated on efforts to revitalize

the IUCD, while AMUA stresses clinical methods of contraception (IUCD and

sterilization), and the AMKENI project targeted all modern forms of contraception. The

presence of these projects with similar end points (i.e., increase in LAPM use) in one

country affords an opportunity to examine more closely the longer-term outcomes and

impact of each intervention, and to determine what combination of these approaches

might be best for increasing LAPM use.

Objectives

The overall goal of this project is to inform the design of future LAPM revitalization

efforts by comparing and contrasting the various interventions that have recently taken

place in Kenya. This comparative assessment addresses several research objectives:

• Describe interventions conducted in Kenya from 2000-2007 as part of the

initiative to increase LAPM and IUCD use, including program managers’ views

on the strengths and limitations of the interventions.

• Describe the pre- and post-intervention LAPM utilization levels for facilities

participating in each intervention, where it is available.

iii The Ministry’s strategy has four components: 1) consensus-building and advocacy, 2) building capacity

and improving service delivery, 3) demand creation, and 4) monitoring and evaluation.

iv The ACQUIRE project also included elements of advocacy.

Kenya Ministry of Health, LAPM Comparative Assessment

14

Version 1.2 September 30, 2008

• Describe levels of knowledge and attitudes among family planning (FP) clients

and providers in sites that were subject to one or more interventions about LAPM.

• Determine the key determinants influencing clients who choose LAPM.

Methods

There was no attempt to attribute results to a single intervention (due to geographic

overlap of the projects), but rather we employed a multiple-case study (comparative)

approach. A multiple-case study design is ideal to address these objectives because case

studies provide more context than typical study designs, giving the “story behind the

result.”

6

The formal definition of a case study is “an empirical inquiry that:

1) investigates a contemporary phenomenon within its real-life context; when

2) the boundaries between the phenomenon and context are not clearly evident; and

in which

3) multiple sources of evidence are used.”

7

A limitation of using a case study design is that one cannot make causal conclusions

based on its results. Due to varying intervention start dates, the differing lengths of time

during which interventions took place, selective recall of events, the differing times

required for interventions to mature into their most effective state, and the reality that the

context relating to LAPM changed in the last several years as national programs

expanded, no study design could address the issue of causality. Hence, we employed a

study design that is exploratory instead of experimental.

Each of three major LAPM-related interventions (AMKENI, ACQUIRE, AMUA) was

defined as a “case.” Each case was, in turn, examined in several sites (i.e., facilities,

communities). We purposively selected 10 facility sites to represent each of the three

major interventions. We asked projects to identify some sites where the interventions

worked particularly well, and some where there were more difficulties. The 6 sites

examined in the ACQUIRE case study were part of a larger case study on the ACQUIRE

project done by EngenderHealth.

We limited site selection to the western part of Kenya, where the interventions came

closest to overlapping geographically, both for logistical reasons, and to keep the areas as

comparable as possible. We collected data from AMKENI sites in Western Province,

ACQUIRE sites in the Kisii District of Nyanza Province, and AMUA sites in Rift Valley

Province.

v

Data on ACQUIRE sites were collected from February to August 2007. Data

from AMKENI and AMUA sites and interviews with national and program-level

stakeholders were collected in June and July 2007 (Table 1). Because the ACQUIRE

case study had been designed before this comparative analysis was conceived, the types

of information collected at ACQUIRE sites were slightly different than those collected at

AMKENI and AMUA sites.

v Note: two of the “AMUA” facilities are public sector facilities that participate in the TL mobile clinics

with Marie Stopes Kenya. Stakeholders in the AMKENI project in Coast Province were also interviewed.

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

Table 2: Data collected at 26 sites included in the comparative assessment

AMKENI

(N=10 sites)

AMUA

(N=10 sites)

ACQUIRE

(N=6 sites)

Type of data

Stakeholder interviews

26

In-depth interviews

Provider interviews

26

14

6

Closed-ended questions

Facility in-charge interviews

9

10

n/a

Closed-ended and open-

ended questions

Client exit interviews

60

28

6

Closed-ended questions

Facility audits

10

10

6

Facility infrastructure

and stocks

Champions

n/a

n/a

8

In-depth interviews

CBD agents

0

0

12

In-depth interviews

Peer educators

0

0

16

In-depth interviews

LAPM user interviews

IUCD users

16

9

4

In-depth interviews

Implant users

8

14

n/a

In-depth interviews

Tubal ligation users

18

7

n/a

In-depth interviews

Vasectomy users

3

0

In-depth interviews

Total LAPM users

45

30

4

Pre and post-intervention FP provision

8 sites

10 sites

13 sites*

Service statistics

* Service statistics were available for all 13 of the ACQUIRE pilot sites, but the interviews only took place in 6 pilot sites.

The primary data used to compare the interventions were the pre- and post-intervention

levels of contraceptive provision at the service delivery sites (Table 1). In addition,

program managers, providers, and clients were interviewed at all the sites included in the

study. Secondary data were examined through project reports (see Appendix for list of

documents reviewed). Family Health International (FHI) led data collection efforts at the

AMKENI and AMUA sites. EngenderHealth led data collection efforts at the ACQUIRE

sites. One weakness of this study is that peer educators and community-based

distribution agents were not interviewed at the AMKENI and AMUA sites. It is also

important to note that with small sample sizes and purposive selection of facilities, this

assessment can only be generalized to the few facilities and clients included in the data

collection. This report is not meant to be a definitive representation of the experiences in

the three interventions, but rather is meant to highlight differences, similarities and

recommend the direction of future LAPM interventions.

Data from knowledge, attitude and practice (KAP) questionnaires of clients, providers

and program managers, and service statistics were entered into a quantitative database in

the FHI office in Nairobi, using EpiInfo software. The quantitative data were compiled

into descriptive tables and stratified by the intervention type. In-depth interviews were

recorded and transcribed into English in Nairobi. Transcripts were then analyzed for

common themes.

Results of the interventions: LAPM uptake

All three interventions observed increases in LAPM utilization. In its 96 facilities, the

AMKENI project achieved a 129 percent increase in annual IUCD insertions from

baseline to the end of the project, a 48 percent increase in implant provision (although

utilization varied significantly depending upon available stock), and a 363 percent

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

increase in annual TLs performed. At 36 months into its intervention, the 141 AMUA

Network franchisees had provided 20,514 TLs to women seeking FP, and inserted 15,020

IUCDs in family planning clients. The ACQUIRE project observed a 122-percent

increase in IUCD use overall in Kisii District between January 2005 and December 2006

and a 403-percent increase in the 13 ACQUIRE-supported facilities.

Direct comparisons among the interventions are difficult because of their differing

objectives and sizes. However, all three interventions targeted the IUCD. To facilitate

comparisons, this assessment examined a small, comparable number of sites for each

intervention. Table 3 demonstrates that while percentage increases in IUCD uptake were

impressively high at the peak of each intervention, the maximum average monthly

provision of IUCDs in each facility was still relatively low. At their peak, the eight

AMKENI sites provided approximately six IUCDs per site per month. The 10 AMUA

sites provided a high of three IUCDs per site per month. By contrast, the six-month

period high for the 13 ACQUIRE pilot sites was 12 IUCDs provided per site per month.

Table 3: Comparison of LAPM uptake at peak among interventions

IUCD

Sterilization*

Implants

% Increase

in uptake

Average

number per

site per

month

% Increase

in uptake

Average

number per

site per

month

% Increase

in uptake

Average

number per

site per

month

AMKENI

1187

8

685

8

2592

7

AMUA

160

5

477

6

n/a±

n/a

ACQUIRE

734

12

**

1

168

4

* Sterilization includes both female and male sterilization, but the vasectomy numbers were negligible.

± Implants were not available in the AMUA Network at the time of data collection.

** Unable to calculate percentage increase, since provision at baseline was 0; peak provision was 45 sterilizations

performed in 13 sites in quarter 2 of 2007.

The assessment collected utilization data for eight AMKENI sites 15 months after the end

of the intervention, allowing an examination of the intervention’s longer-term results

(Figure 1).

vi

AMKENI concluded in March 2006, at which time the eight sites were

providing increased numbers of IUCDs, implants and TLs as compared to July-December

2000. Since the project concluded, the number of TLs provided has dropped to near-

baseline levels, but the number of IUCDs and implants provided remains elevated. This

provides some evidence that the AMKENI project had a modest sustained impact on

LAPM provision, especially IUCDs.

Figure 2 presents data from eight AMUA facilities and two MOH facilities that

participate in the MSK TL mobile outreach. More clients have received TL services in

these facilities in the past three years than have received IUCDs. Indeed, MSK did not

meet its mid-term targets of couple-years of protection (CYP) provided because of lower

than expected IUCD uptake.

vii

Low uptake also resulted in the cost per CYP exceeding

vi Unable to obtain data for 2 of the 10 AMKENI sites in this assessment. There were also data missing for

Q2 2006, Q3 2006, and Q2 2007. These quarters were estimated based on available data.

vii CYPs were calculated using standard conversion factors specified by the United Nations Population

Fund.

Kenya Ministry of Health, LAPM Comparative Assessment

17

Version 1.2 September 30, 2008

the target of €4 per CYP. At mid-term each CYP cost approximately €24. Since the other

two interventions studied did not calculate this important indicator, we are unable to

compare the relative costs of the interventions.

Figure 1: Semi-Annual Provision of LAPM in Eight Former AMKENI Sites

in Western Province

0

50

100

150

200

250

300

350

400

Jul-Dec

00

Jan-Jun

01

Jul-Dec

01

Jan-Jun

02

Jul-Dec

03

Jan-Jun

03

Jul-Dec

03

Jan-Jun

04

Jul-Dec

04

Jan-Jun

05

Jul-Dec

05

Jan-Jun

06

Jul-Dec

06

Jan-Jun

07

IUCD

Implants

TL

Project end

(March

2006)

Figure 2: Semi-Annual Provision of IUCD and Tubal Ligation (TL) in

Ten AMUA/MSK-supported Facilities in Rift Valley Province

0

20

40

60

80

100

120

140

160

180

200

Jan-Jun 05

Jul-Dec 05

Jan-Jun06

Jul-Dec 06

Jan-Jun 07

IUCD

TL

The ACQUIRE project achieved dramatic increases in IUCD provision from the start of

the project in early 2005 to the end of the project in January of 2007, and provision

continued to increase even after the project end (Figure 3). Conversely, in the ACQUIRE

supported facilities there appeared to be little change in provision of TL and implants.

Although the project specifically targeted 13 facilities and the IUCD, Kisii District as a

whole also experienced a five-percent increase in all FP clients, and a 19-percent increase

in uptake of female sterilization (data not shown).

Kenya Ministry of Health, LAPM Comparative Assessment

18

Version 1.2 Septembe

Ken

r 30, 2008

ya Ministry of Health, LAPM Comparative Assessment

19

Short-term reactions to intervention activities

Figure 3: Semi-Annual Provision of LAPM in 13 ACQUIRE-supported

Facilities in Kisii District

0

100

200

300

400

500

600

700

800

900

Jan-Jun06

Jul-Dec 06

Jan-Jun 07

Jan-Jun 05

Jul-Dec 05

IUCD

BTL

Implants

Project end

(Jan 2007)

It is also useful to examine monthly variations to observe how sensitive uptake is to

supply-side and demand-side interventions. Figure 3 smoothes out monthly variations by

showing six-month totals for ACQUIRE sites, and only presents data through June 2007.

Figure 4 depicts the monthly statistics for IUCD insertions in 13 ACQUIRE sites in Kisii

District from January 2005-August 2007, and reveals a more complex picture.

Both training events and demand creation activities resulted in immediate spikes of IUCD

uptake. For example, following the contraceptive technology update (CTU) trainings of

August and September 2005, and the October 2005 IUCD clinical training, the number of

IUCDs inserted at the intervention sites increased. In October 2006, a second IUCD skills

training prompted a 47-percent increase in uptake from the previous month. This increase

might also be linked to the fact that peer educators and CBD agents informed community

members that IUCD training would take place, so clients could go to a specific location

where many providers would be available to provide IUCD services. On the demand

creation side, following the IUCD campaign launch in July 2006, there was a 43-percent

increase in the number of insertions the following month.

Likewise, outside influences were able to spur dramatic drops in uptake. For example, the

number of monthly IUCD insertions in ACQUIRE sites dropped precipitously following

staff transfers and restructuring of the district in July 2007. IUCD insertions recovered

after the staff transfers, and have continued to increase even after ACQUIRE support of

the facilities ended.

Version 1.1 Sep 17, 2008

Kenya Ministry of Health, LAPM Comparative Assessment

20

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

Jan.05

Mar.0

5

May

.0

5

Ju

l.0

5

Sep.05

No

v.05

Ja

n.06

Mar.0

6

May.06

Jul.0

6

Sep

.06

No

v.06

Jan.07

Mar.0

7

M

ay.07

Jul.0

7

Sep.07

No

v.07

Ja

n.08

Mar.0

8

IUCDs inserted

District

Restructuring,

Staff Transfers

May-Jul. 2007

Apr-Jun 2008 IUCD Uptake

681% Higher than at baseline

(Jan. 2005)

Figure 4: Monthly Provision of IUCD in 13 ACQUIRE-supported Facilities in Kisii District

.

Stakeholder

Meeting

Feb. 05

CTU Trainings

Aug. & Sept. 05

IUCD

Clinical

Skills

Training

Oct. 05

December is

historically a slow

month for FP

clients – IUCD

trained providers

were on holiday –

Increased Uptake

in Jan. 06

CBD Agent

and Peer Ed.

Training April &

May 06

IUCD

Campaign

Launch July

06

FP Counseling

Training & TOT

for CBD

Supervisors

Feb. 06

PNA May 05

2nd IUCD Skills

Training

Oct. 06

Project

Ends

Dec. 2006

Depo

Stockout

Jan.-Feb.

2007

Advocacy

Demand

Supply

Version 1.1 Sep 17, 2008

General sustainability of the interventions

This comparative assessment does not explicitly address the long-term sustainability of

these interventions, given that the AMUA project is ongoing, and the follow-up periods

for AMKENI and ACQUIRE were different. However, a review of LAPM uptake in

sites from the AMKENI and ACQUIRE interventions is possible. Examining LAPM

provision over a seven-year period in several former AMKENI facilities showed mixed

results. The number of clients receiving some types of LAPM (including IUCD) did not

return to baseline levels, but remained elevated over one year after the project ended.

This increase was observed in a selection of high- and low-achieving AMKENI facilities,

which may approximate an average level of achievement for AMKENI facilities. Yet

provision of TL quickly returned to baseline levels after AMKENI ended. Trends in

ACQUIRE-supported sites were different, where provision of IUCDs continued

increasing post-intervention. TL and implant provision remained fairly steady

throughout the intervention period, which was unsurprising as the demand creation

activities focused on the IUCD.

The remaining sections of this report detail the various activities of each intervention, and

the output data associated with these dimensions of LAPM provision. Three major types

of activities were conducted: activities to ensure an adequate supply of trained personnel;

efforts to make equipment, supplies, and commodities available; and efforts to increase

demand for LAPM by confronting myths and misperceptions and increasing knowledge

among potential LAPM clients. Finally, the report discusses promising directions for

future LAPM interventions revealed through the comparative assessment.

Intervention design

Although both the AMKENI and ACQUIRE projects selected facilities in coordination

with the MOH and conducted onsite assessments of those facilities’ needs, some

AMKENI participants noted that they were only passive acceptors of the intervention,

rather than active participants in it. As one AMKENI clinic manager said, “We never

selected…it just rolled down to us. So [the MOH] was just coming with issues. We never

sat down to select, we were just receiving them from above.”

By contrast, ACQUIRE staff frequently mentioned the importance of obtaining

stakeholder buy-in and participation from the onset as a best practice. The PNA and

stakeholder workshops were seen as critical activities in gaining buy-in. A supervisor in

an ACQUIRE pilot site noted that decisions were taken in partnership with providers at

the facility; he noted that ACQUIRE “… did not come in and say ‘do this, do this.’” It

appears that top-down approaches are less accepted than participatory approaches, such

as that used in the ACQUIRE project, where ownership is mainstreamed at all levels.

Ensuring an adequate supply of trained personnel

Since LAPMs are clinical methods, special attention must be paid to training; all three

major interventions included large provider training components. In the first years of the

AMKENI project, tutors and lecturers from Kenya’s medical training colleges were

Kenya Ministry of Health, LAPM Comparative Assessment

21

Version 1.2 September 30, 2008

trained to strengthen the knowledge base of the pre-service trainers. In addition, 3,086

providers attended AMKENI-sponsored training in clinical and counseling topics. The

range of services at AMKENI-supported sites expanded significantly during the project’s

lifetime. District level officers and the decentralized reproductive health training and

supervision teams were targeted in trainings to improve supervision and training skills.

AMUA franchisees received comprehensive training in counseling for IUCD and TL, and

insertion techniques of IUCD, as well as general reproductive health technical updates.

Franchisees were also invited to attend Continuing Medical Education (CME) sessions,

and AMUA trainers make occasional visits to offer technical assistance concerning any

queries and problems that might arise. The ACQUIRE project also conducted provider

clinical and FP counseling training, focusing on the IUCD, and general contraceptive

technology updates.

Provider training experiences

When providers were surveyed in 26 facilities —10 AMKENI, 10 AMUA, and 6

ACQUIRE— more than half said they had been trained on IUCDs and implants in the

previous five years (Table 4). Only about one in five had received TL training, and only

five of the 46 providers interviewed had received any training about vasectomy in the

past five years. It is important to note that it might not actually be appropriate to train

these providers on these services, either because the health site is not equipped to provide

them, or they are not in the cadre of providers allowed to provide them.

A higher percentage of providers in ACQUIRE sites received FP counseling training

than in AMKENI and AMUA sites. A majority of providers in AMKENI and AMUA

sites said they had attended a contraceptive technology update. Similarly, 51 providers

from 26 sites in Kisii received a contraceptive technology update from ACQUIRE. By

comparison, the Kenya Service Provision Assessment of 2004 found that only about one-

quarter of providers or fewer had received an update on FP methods in the past 35

months in the provinces covered by these interventions (Western 23%, Rift Valley 28%,

Nyanza 19%).

11

AMKENI

(N=26 providers)

AMUA

(N=14 providers)

ACQUIRE*

(N=6 providers)

IUCD

65

79

83

Implants

54

71

n/a

Tubal ligation**

16

29

n/a

Vasectomy

0.1

0.2

0

FP counseling

54

50

83

Contraceptive technology update

73

64

67

Facilitative/Supportive supervision

30

50

83

n/a= not available

*Kisii providers were asked if they received training in the past two years

**Only facilities that have surgical capability can offer tubal ligation; however providers in all facilities were

queried about recent TL training.

Table 4: Percent of providers who received training in the past five years, by training type

Providers almost universally said that they applied what they learned in the trainings to

their current work, and many facility in-charges emphasized that providers need

Kenya Ministry of Health, LAPM Comparative Assessment

22

Version 1.2 September 30, 2008

continuous training to stay up-to-date with current medical evidence. For example, one

facility in-charge said, “If the staffs are not updated from time to time, they tend to go

with the old information…” Another said: “Some people who have been in the field for

long and have not had refresher courses have even forgotten…If they are reminded, they

can improve the service. Seminars are very important, actually.”

A provider in an ACQUIRE site explained the impact of the counseling training this way:

“[I] tried to identify which clients wanted to space, delay, become pregnant … [so I]

created a rapport with clients.” This provider noted that, in the past, she did not provide a

lot of information to clients, but because of the training, she now talks to clients more,

and fills in the gaps where they do not have information.

On average, about half of providers said they had received training on facilitative/

supportive supervision in the past five years, although this varied by intervention (Table

4). Nearly all of those who underwent supervision training said they were able to apply

what they learned to their job. Providers most often said the training resulted in them

supervising their staff more frequently, and instructing their staff members better.

Availability of LAPM services

Despite many provider trainings on LAPM, access to these services is not universal.

Although all facilities in the assessment should technically provide IUCD services, only

about three-quarters of providers reported that they had ever personally inserted an IUCD

(Table 5). A similar number of providers said they were trained to provide implants. Only

about half of facilities included in the assessment provided TL services in their facility,

viii

although it is likely that in many facilities, the only TL services are provided by a Marie

Stopes Kenya (MSK) mobile clinic. All of the AMUA sites and seven of 10 AMKENI

sites participate in MSK’s mobile outreach. Fewer than half of providers said their

facility offers vasectomy services.

AMKENI

(N=26 providers)

AMUA

(N=14 providers)

ACQUIRE

(N=6 providers)

Provider ever personally inserted an

IUCD

72

79

83

Provider trained to provide implants

70

83

n/a

Provider said facility provides TL*

42

64

n/a

Provider said facility provides vasectomy

42

43

n/a

n/a= not available

*Only facilities that have surgical capabilities can offer tubal ligation.

Table 5: Facility readiness to provide LAPM

Training of private sector providers

The proportion of Kenyan FP users receiving their methods from the private sector has

increased in recent years. In 1988, 27 percent of FP users in Kenya said their source of

FP was the private sector; in 2003, this had increased to 41 percent.

3;4

Although the

purview of the MOH includes both the public and private health sectors, private sector

providers have not always been included in MOH activities (e.g., trainings). Many private

viii Ten of the 12 ACQUIRE sites were dispensaries or health centers where TL services are not provided.

Kenya Ministry of Health, LAPM Comparative Assessment

23

Version 1.2 September 30, 2008

sector providers participating in the AMUA project expressed gratitude for being

included in MOH activities again. As one private sector provider said, “Another success

[of AMUA] is the training of the personnel. [Staff members] go for short-term courses in

the MOH. [But] … in [the] private [sector], there is none unless maybe you go back to

school. Anyway, it is difficult, because you cannot, it will mean closing [the clinic]. So,

when they come and provide these short courses which take a short time, actually I think

they have really helped the providers.”

As the quote above implies, training activities for private sector providers must also take

into account their working hours and identify the most convenient times for them. For

example, the continuing professional development (CPD) workshops organized by the

MOH and FHI for private sector providers took place on Friday evening and Saturday

morning to minimize the time that providers would be absent from their facilities.

Maintaining a trained workforce

Maintaining a trained workforce in facilities following training interventions is an

ongoing issue. Respondents reported frequent transfers of trained providers to other

departments or facilities where they no longer use the skills they acquired through the

interventions. A respondent from Coast General Hospital illustrates these concerns: “One

thing you should be aware is that there is very high job staff mobility. [Providers] don’t

seem to stick in one facility for long…, the new who are being employed are very mobile.

Our doctors, our nurses are very ambitious; they don’t want to be in one place for a long

time. If you try to trace some of the few who were trained two or three years ago, you’ll

find that they are all over — one is in Australia, one in America, one is in another place

— it’s very disturbing, and that’s why we will never be able to fully train people … to

our satisfaction.” Demonstrating this point, the provision of IUCDs in ACQUIRE sites

dropped sharply after staff transfers in July 2007 (Figure 4).

Provider behavior and attitudes

Past research demonstrated that both provider skills and attitudes constitute a barrier to

LAPM use.

12;13

Most providers said their opinion about IUCDs has changed in the last

five years, although we did not ask them to specify why or in what direction the change

had occurred (Table 6). All the interventions updated providers on the new medical

eligibility criteria (MEC) for IUCD use, which open the way for many more women to

use the method. While more than 80 percent (81%, 86%) of providers involved in

AMKENI and AMUA

interventions correctly

thought that the IUCD

could be an appropriate

method for young

women, only about half

(52%) of providers in

AMKENI facilities, and

71 percent of providers in AMUA facilities, thought that the IUCD was an appropriate

method for nulliparous women, despite the fact that the MEC state that nulliparity should

Table 6: Percent of providers whose opinions about LAPM changed

AMKENI

(N=26 providers)

AMUA

(N=14 providers)

Opinions changed in past five years about…

IUCDs

85

86

Implants

69

64

Tubal ligation

77

71

Vasectomy

65

43

Kenya Ministry of Health, LAPM Comparative Assessment

24

Version 1.2 September 30, 2008

not be a contraindication for IUCD use. The differences between AMKENI and AMUA

sites may be reflective of the differing training components of the interventions.

Over half of the providers interviewed for this assessment said their opinions about

implants had changed in the past five years, and almost three-quarters had changed their

opinion about TL (Table 6). Only about half said they had changed their opinions about

vasectomy. Providers said that the long-acting effectiveness of TL is both its greatest

advantage and disadvantage for clients. This belief was mirrored by clients who said that

TL was a good method for women, but only when they had borne their desired number of

children. Providers had similar praise and complaints about vasectomy being a permanent

method, but were less likely to report always counseling clients about vasectomy

compared to TL. (Table 7) The long-acting effectiveness of the method, and the fact that

it required clients to come to the clinic less frequently, were the most oft-cited advantages

of implants.

Attitudes may affect how providers counsel about LAPM. Following the interventions,

providers in AMKENI and AMUA sites were asked their attitudes about LAPM and their

counseling behaviors. A large majority of providers said that they always counsel clients

about IUCDs, implants, and TL (Table 7). However, there is a gap between what

providers say they give counseling

about, and what clients report that

providers do. Among the few clients

interviewed who were coming to the

facility for a new method (AMKENI

N=19, AMUA N=5), fewer than half

said that the provider discussed the

IUCD, TL, or vasectomy with them.

Clients were more likely to report that

providers discussed implants with them (AMKENI 74%, AMUA 60%).

Table 7: Percent of providers who say they counsel

about LAPM

AMKENI

(N=26 providers)

AMUA

(N=14 providers)

Always counsel clients about…

IUCDs

92

86

Implants

81

93

Tubal ligation

85

86

Vasectomy

39

71

A smaller fraction of providers said they always counsel clients about vasectomy, mainly

because men don’t come to their facilities, and clients don’t ask for the method. We were

not able to determine whether providers were neglecting LAPMs in their counseling

sessions, or simply using targeted counseling with their clients.

Provider biases remain, particularly about the IUCD

In order to change provider behaviors, ongoing training should be matched with

advocacy efforts that address biases that are a function of long-held, but erroneous

beliefs. Provider biases against certain methods (notably the IUCD) remain. For example,

providers continue to worry unnecessarily about facilitating infections in their clients

through IUCD provision. Over half of the providers in AMUA facilities said they were

concerned about the association between IUCD and infections (57%). It seems logical

that continuing education of providers and improving pre-service training on LAPMs

could help to address some of these problems in the future.

Kenya Ministry of Health, LAPM Comparative Assessment

25

Version 1.2 September 30, 2008

More providers in AMKENI sites thought that clients were not receptive to the IUCD

than in AMUA or ACQUIRE sites (AMKENI 42%, AMUA 14%, ACQUIRE 11%). All

providers agreed, however, that what prevents clients from desiring the IUCD are the

rumors and myths prevalent in the communities. Providers also felt that clients who are

receptive to the IUCD are those who listen to what their providers say, indicating that

providers believe they have great influence over the methods chosen by their clients.

There was also some evidence among both providers and clients in AMKENI and

AMUA sites that they do not perceive the IUCD as being effective at preventing

pregnancy. One in-charge of a former AMKENI site said “I know of three cases — two

are my sister-in-laws, and one was just a staff [member] — who complained that…they

conceived with the coil [IUCD]. So I tend to think that possibly the coil could not be

doing so well.”

ix

This adverse experience could be related to the quality of provision. If

inexperienced providers are not placing IUCDs properly within the uterus, clients could

be experiencing high rates of expulsion that would leave them vulnerable to unwanted

pregnancies. Another in-charge noted that providers need to improve their insertion

skills: “It comes back to us, the service providers, to have the skills in fixing long-acting

methods to these clients so that we do not have the failure rate.”

Facility and provider incentives

In both the private and public sectors, interventions need to consider how to motivate

providers to interest them in LAPM provision. The AMUA Project intended to include

doctors in the network so that they could perform sterilizations. They were unable to

recruit doctors, however, because they did not see any monetary benefit in providing

sterilizations.

The time required to provide a clinical method may also serve as a disincentive. One

AMUA in-charge noted that some providers “try to de-motivate the clients from using the

IUCD” because of the effort that goes into its provision. An AMUA program officer

explained in more detail, “For the providers, they are doing [IUCDs] though with a lot of

difficulty. They see the procedure as somehow very long, and … they are spending a lot

of time and resources while the income is not coming in the process.”

Although its role as a possible provider disincentive in the public sector is often ignored,

public sector providers also noted the cost of LAPM provision. As a public sector facility

manager said, “If TL is provided for free, who will bear the cost of the TL to the

institution? Institutions are told to look for ways of generating income … 150 shillings is

just for sutures, what about the blade? What about the consumables? How do we meet the

cost in between? From an administrative perspective, I think TL is not the best operation

to take to theatre. Why? Because it saps on the resources.”

Beyond the issue of cost-recovery, providers in both sectors might be amenable to

motivation from non-monetary sources. For example, providers who participated in the

ACQUIRE project expressed satisfaction at having been thanked by their clients. Also,

some providers noted that increasing the number of clients using LAPM had reduced

ix It is possible that this facility manager was not trained under the AMKENI project.

Kenya Ministry of Health, LAPM Comparative Assessment

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their FP client load, which could be a strong motivation in facilities with long queues of

clients. If providers are not rewarded somehow for giving LAPM, their motivation to

supply these more labor intensive methods may remain small.

Making commodities, equipment and expendable supplies available

In addition to training providers in the provision of LAPMs, the projects pursued diverse

strategies for making commodities, equipment, and expendable supplies available in their

sites. With its larger budget, AMKENI was able to address clinic infrastructure and

conducted 56 renovation projects at AMKENI-supported health facilities. Both AMKENI

and ACQUIRE provided essential equipment at their sites. The equipment provided to

AMKENI sites ranged from basic items such as blood pressure machines, minilap/TL set,

vasectomy set,

lantern/torches,

sign boards,

examination

couches,

fridge, as well

as IUCD kits

x

with

specialized

equipment,

such as

autoclave

sterilizers,

anesthetic machines, oxygen concentrators, and operating tables. The ACQUIRE project

worked to ensure that sites were ready for IUCD provision, and thus distributed IUCD

supplies (two complete IUCD kits per site) and sterilization equipment distribution where

needed, including non-electric autoclaves. ACQUIRE sites with high client load were

supplied an additional autoclave to help reduce waiting times between IUCD clients.

Figure 5: Percentage of facilities with all items and conditions

for quality IUCD and implant insertion

0%

20%

40%

60%

80%

100%

IUCD

Implant

AMKENI

Amua

ACQUIRE

The AMUA project provided equipment to its franchisees on a cost-sharing basis. Each

franchisee could request the equipment it needed (i.e., autoclave, examination bed,

portable light source, etc) and receive it directly from AMUA. The franchisee was then

responsible for paying back half the cost of that equipment, upon which time it would be

wholly owned by that facility. In addition, the AMUA project facilitated private sector

provider access to public sector commodities, and ensured product supplies if the public

sector system should stock-out. An AMUA project manager noted that it is important that

the MOH recognizes private sector members of the AMUA network as partners and not

competitors. Through the efforts of AMUA, franchisees were able to obtain free FP

commodities from the public stores in their districts.

x

The IUCD kit was a minimum package required for IUCD provision as agreed upon by the MOH IUCD

task force. It contains a deep, large oblong/rectangular tray with lid, sponge holding forceps, speculum

(medium size), 2 gallipots, 1 medium 120ml and 1 small, Simsons 9" graduated uterine sound, curved long

scissors, long straight artery forceps, and alligator forceps

Kenya Ministry of Health, LAPM Comparative Assessment

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All of the Kisii facilities (13/13) were fully equipped for IUCD insertion and removal

when they were observed a few months following the ACQUIRE intervention. However,

only 2/10 and 7/10 of the former AMKENI and AMUA facilities, respectively, were fully

equipped for IUCD insertion and removal, and only 1/10 and 2/10 facilities, respectively,

were equipped for implant insertion and removal at the time of facility audits (Figure 5;

implant data not available for ACQUIRE). The most commonly missing elements were a

portable light source or adequate lighting and clean running water, but many other

elements were also missing in at least one facility. A 2004 service provision assessment

(SPA) in Kenya found that country-wide, only 50 percent of facilities had both IUCDs

and the basic equipment necessary for IUCD removals and insertions.

11

At the time of auditing the 26 facilities examined for this assessment, there were several

stock-outs of contraceptive methods, mostly DMPA (injectable). Among the 22 former

AMKENI and ACQUIRE facilities, only two had DMPA in stock. Nine of the 10 AMUA

facilities had DMPA in stock. This is perhaps because AMUA provided contraceptive

stocks to its franchisees from a central stockpile at the Marie Stopes Kenya offices in

Nairobi in the case of stock-outs from their regular district-level sources of commodities.

Other contraceptive methods that were out of stock during the facility audits included

female condoms (available in 4/10 AMKENI and 8/10 AMUA facilities), and combined

oral contraceptive pills (available in 7/10 AMKENI and 9/10 AMUA facilities).

Emergency contraceptive pills were available in 6/10 AMKENI and 6/10 AMUA

facilities.

Commodities, equipment and expendable supplies remain a problem

Ensuring adequate commodities and other consumable supplies for LAPMs is a constant

challenge, and one shared with other FP methods. Implants were stocked out at least

twice over the past seven years, and during the assessment’s fieldwork period, injectable

contraceptives were out of stock. Stock-outs force clients to choose methods they did not

originally prefer. Several LAPM users interviewed said that they had chosen their method

because of the injectable stock-outs. A 20-year-old mother of two who chose an implant

rather than the injectable she preferred said, “If you come for something like an

injectable, you are told that it is not available. Alternatively, if you ask for injectable you

are given [it], but when you are given an appointment for the next visit, you don’t find

[the injectable] there. I thought that can affect me, so I decided to go for [Norplant].”

Similarly, ACQUIRE’s Performance Needs Assessment in Kisii District also found that

some FP clients used DMPA because other methods were not available.

As mentioned above, AMUA franchisees were eligible to purchase subsidized equipment

for the provision of IUCD at a cost of 50 percent less than the market price. It may be that

owning the equipment led private sector providers to utilize it more carefully. The fact

that AMUA and ACQUIRE facilities are more likely to have all the elements needed for

IUCD provision could also reflect the recency of those projects, as compared to

AMKENI. Data collection took place approximately 15 months after the end of the

AMKENI project, and only 20 percent of those facilities had all the elements required for

IUCD provision. Assuming that the AMKENI facilities were fully provisioned until the

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end of the project in March 2006, it seems that improved systems are needed to ensure

that equipment and supplies remain available after an intervention has ended.

Improving knowledge and confronting myths to help create demand

Counteracting myths and misconceptions and providing clients with factual information

about LAPMs were the goals of the community outreach and demand creation activities

of the three projects. Where the AMKENI project focused principally on community

outreach for demand creation, both ACQUIRE and AMUA also included mass media

elements in their demand creation activities.

Community-based distribution agents and peer educators

All three interventions included community-based distribution (CBD) agents and

volunteer peer educators in their demand creation activities. AMKENI’s behaviour

change communication (BCC) component worked with communities to increase demand

for LAPM. The project held direct outreach activities targeting families, men, women,

and youth through traditional media and established discussion networks. From 2001

until 2006, AMKENI worked with approximately 1,000 volunteers and 3,000 community

groups in long-acting, continuous BCC activities. More than 600,000 community

members participated in various BCC and health education activities (i.e., Health Action

days, Mothers Days, and Female Sterilization outreaches).

The AMUA franchising network adopted a commission system to encourage

approximately 250 CBD agents to work with the project. When a CBD agent brings a

client to a TL clinic, she receives Ksh100 (approximately US$1.50). The CBD agent

accompanies the client to her appointment, takes care of her baby during the procedure (if

necessary), takes the client home, and looks after her post-operatively.

A total of 72 male and female peer educators

were recruited from faith based organizations,

women’s organizations, and youth groups, and

were trained as part of the integrated ACQUIRE

communication campaign. From August 2006 -

December 2006, peer educators reported

meeting with approximately 50,000 people

throughout Kisii District at approximately 2,700

community events. The events included

weddings, funerals, PTA meetings, church

meetings, women’s groups, youth groups, and

barazas. CBD agents were also directly linked to

each of the 13 sites participating in the pilot to

help facilitate community access to FP methods

and information.

Figure 6: Peer educators and CBDs from

ACQUIRE Project

When interviewed for the assessment, providers at the AMKENI, AMUA, and

ACQUIRE facilities agreed that CBD agents and peer educators had improved

Kenya Ministry of Health, LAPM Comparative Assessment

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community opinions about LAPM. Ten of 30 FP clients at the AMKENI facilities who

had heard about the IUCD in the past six months received this information from CBD

agents, whereas only 1/9 AMUA clients reported the same (information not available for

clients at ACQUIRE sites). Nonetheless, CBDs were considered by program managers to

be an integral part of the AMUA intervention, and perceived as responsible for most of

the promotional work in the project. An earlier operations research study in Western

Kenya found that including CBD agents in IUCD promotion activities was more effective

than using providers only, although the intervention was not cost-effective, since the cost

per 3.5 years of pregnancy protection associated with additional IUCDs provided was

$49.57 per IUCD client as compared to $15.19 for the same years of pregnancy

protection for a DMPA client.

(12)

Both providers and clients suggested that one of the best ways to improve clients’ views

about specific methods may be by using peer education, particularly satisfied users of that

method. Providers at ACQUIRE sites noted that peer educators served several functions,

including removing client fear of providers; giving messages in villages and bringing

clients; removing myths; and creating a link between providers and the community at

large. A 44-year-old vasectomy user said, “Those who have done [vasectomy] should be

identified as role models for those who don’t know its importance. They should be in

touch through family planning and NGOs dealing with FP.” And an AMUA facility in-

charge noted, “When we started off, [acceptance of the IUCD] was very poor. After

those clients who had accepted the method talked to others, the numbers came up.” The

ACQUIRE project featured satisfied users in some of its radio shows, but no specific data

were gathered on their effect.

Media campaigns

ACQUIRE designed a communications campaign based on data from the 2003 DHS and

focus group discussions to address women’s and men’s views about the IUCD. Using the

slogan, “Now you know the truth,” the goal was to challenge myths and rumors head-on

in order to improve the image of the IUCD in the community. Posters were designed to

convey key messages to challenge myths and rumors about the IUCD directly, and poster

target locations included health care sites throughout Kisii District, pharmacies, and

public spaces. A local media organization was contracted to conduct outreach events,

including four road shows, approximately 30 Ladies Clubs, and 10 Chief’s Barazas.

Roughly 11,000 people attended the four road shows.

A brochure of in-depth technical information on the IUCD was also created as part of the

ACQUIRE campaign. Peer educators and providers were the primary media for brochure

distribution. A leaflet was also created for distribution at large audience events. Two

different radio advertisements were created in Kiswahili: One advert addressed the fact

that the IUCD does not negatively affect a couple’s love life; the second ad addressed the

fact that using the IUCD does not negatively affect a woman’s ability to work. The

advertisements ran on Citizen Radio, a national radio station, Kisii Service Radio, and

Egesa FM, a local Kisii station. As part of the radio campaign, 10-minute informational

call-in shows were also conducted on Friday mornings on Egesa radio. These programs

Kenya Ministry of Health, LAPM Comparative Assessment

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Version 1.2 September 30, 2008

hosted guest speakers who provided information on a range of topics, including general

FP, IUCD, and the importance of male engagement in FP.

After implementing its marketing strategy, the ACQUIRE project implemented a

household survey in Kisii District in April 2007, to obtain more information on the

impact of their communications and community initiatives. The survey involved

interviewing 346 married or cohabiting adults aged 20 - 49, with a gender breakdown of

respondents of 50 percent female and 50 percent male.

xi

These respondents were sampled

to represent the general population of Kisii District, not just FP users.

In the six months prior, 45 percent of these respondents reported hearing or seeing IUCD

advertising. The majority of respondents cited radio, posters, and providers as sources of

exposure. Mass media was the most mentioned. Overall, almost one-quarter of both men

and women cited the radio program (phone-ins/expert interviews) as the best source for

information. Nearly one in five respondents had attended a community session focused

on the IUCD. Following those sessions, respondents were likely to take some action

about FP, such as talking to a partner or family/friend. ACQUIRE project staff members

concluded that while advertising encourages method awareness and consideration,

community sessions are integral to driving people to action.

Stakeholders also expressed satisfaction with the ACQUIRE campaign and the materials.

A provider noted that the radio messages helped clients to have a certain level of

knowledge when they came to the facilities. As a result, clients were more educated about

FP and the IUCD, thus making the job easier for the provider. Providers used the

brochures to show the female anatomy while counseling FP clients. Providers also noted

that they used the posters to show clients how women can work when using the IUCD,

and explained that the IUCD will not have a negative impact on sexual relations with

their partners.

The ACQUIRE campaign materials and radio advertising were also heard beyond Kisii

District. Approximately 30 percent of the clients interviewed at the AMKENI and

AMUA sites had also heard the IUCD advertisements on a nationwide radio station

(Radio Citizen). A majority of FP clients at AMKENI facilities and about one-third of

AMUA clients said that they had heard about FP outside of the clinic in the past six

months (AMKENI 70%, AMUA 29%). Half of AMKENI clients and one-third of

AMUA clients reported they had heard something about the IUCD in the past six months

(50%, 32%). FP clients were most likely to have seen something about the IUCD in a

brochure or on a poster, but several also mentioned hearing radio advertisements and call-

in shows.

xi The socio-economic status (SES) of the survey sample was representative according to population (7 out

socio-economic class.

Kenya Ministry of Health, LAPM Comparative Assessment

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Figure 7: Sample of AMUA branded clinic,

Nakuru

AMUA’s demand creation activities included

branded marketing of franchises and media

campaigns. Facilities received distinctive

paint schemes, street signs, and IEC materials

(Figure 7). One 37-year-old mother of four

noted that she chose an AMUA clinic for her

IUCD insertion because it was “branded as a

family planning clinic called ‘AMUA’... It is

clear when I come here I am handled with

respect.” AMUA also ran radio spots in local

languages advertising the AMUA network.

Client post-intervention knowledge and

attitudes

The ACQUIRE household survey (described above) showed awareness of the IUCD was

high in Kisii District; 89 percent were aware of the IUCD (spontaneous and aided

awareness). Compared to the 2003 Kenya DHS where only two-thirds of all Kenyan

women surveyed (67%) had knowledge of the IUCD, the ACQUIRE campaign appears

to have had a positive impact on awareness.

(3)

Respondents also had a generally positive

impression of the IUCD. Half of the male respondents and three out of five women

agreed that the IUCD was a “trusted method of family planning.”

of Health, LAPM Comparative Assessment

32

Figure 8: Family planning client opinions about LAPM

(N=88 clients)

52%

38%

13%

41%

32%

34%

35%

22%

42%

52%

20%

40%

60%

80%

100%

26%

14%

0%

Implants

TL

IUCD

Vasectomy

Favorable

Unfavorable Don't know method

Despite community outreach and mass media campaign efforts, relatively large

proportions of respondents reported that their knowledge about a method was insufficient

to make a judgment about it (Figure 8). This may indicate that provider counseling is not

addressing clients’ needs for information. TL is the best-known method among these FP

clients, but the most favorable opinions are about implants. As one facility in-charge

noted, both clients and providers find reasons to like implants: “When [implant] services

are available, the

uptake is high.

One reason is

that it does not

concern the

client so much

because it is

inserted once, it

is not tedious.

Very few clients

complain about

the implant.

Also, the

providers say

that the implant is good.” The major advantage that clients associated with LAPMs was

the long-acting effectiveness or permanence of the methods.

Kenya Ministry

Version 1.2 September 30, 2008

More clients said they did not know about vasectomy than reported any opinion about it

at all. According to providers, many men still view vasectomy as castration. There are

also women who are opposed to their husbands undergoing vasectomy. A national

program manager, commenting on cultural issues, noted, “I think the problem is just the

attitude of our society as far as vasectomy is concerned, because I hear of cases where the

wife herself … refuses her partner to be done vasectomy. I think there is something not

known about the whole issue.” All of the three vasectomy users who were interviewed as

part of the assessment were pleased with the method. Regarding negative public opinion,

one vasectomy user, a 48-year-old father of four said, “After having gone for vasectomy,

people initially started saying that they now learnt to make use of my wife because [I] am

now castrated. But later…they started knowing the truth, and joined me.”

Male involvement

Many communities still view FP as a female issue, which does not involve men at all, but

providers, clients, and stakeholders interviewed for this assessment agreed that involving

more men in FP would help to increase uptake of FP in general, and LAPMs in particular.

While most women say their partners are involved in FP decision-making (AMKENI

85%, AMUA 89%), FP clinics are themselves not seen as “male friendly,” as a

respondent from FHI explains: “Vasectomy has remained low because providers offer

services to the men as if they are … just helping the men. The services are not male

friendly, and it is even referred to as the MCH clinic, so … it is basically for the mother

and child welfare, automatically locking the man out. There are even no clinics that are

specialized to deal with male problems like prostrate cancer or infertility.”

Though there have been many advances in gender equity in Kenya, men are still the

principal decision makers in all matters, including RH/FP. Many women still have

difficulty accessing FP services without their husbands’ approval. One 39-year-old

mother of six who received TL explained why she did not tell her husband about her

intention to use the method before she had the procedure: “I never told him. He knew

after I had already finished doing TL, because if I told him, he wouldn’t agree. And, you

know, a man wants many children. He’s never satisfied with children. He wants many

and yet he can’t take care of them.” The AMKENI project found that peer family

discussion groups could be very effective means of enabling family members to discuss

RH matters openly. In addition, open days, such as Mothers Days, Fathers Days or

community barazas, encouraged discussion around the ambivalence and dilemmas which

accompany the process of effecting behavioral change. As a result, the community

dialogue approach could be very effective in increasing fathers’ involvement in RH

decision making. One clinic in-charge said that they include FP messages in the health

talks they give to outpatient clients who have come to the clinic for treatment. Many of

these clients are men. Stakeholders in the ACQUIRE project reported that men became

much more involved in FP in Kisii District than they had in the past. Peer educators

reached an estimated 21,000 men. Many men listened and called into the Egesa radio

program to obtain more information about family planning. One Kisii District provider

noted that after she spoke about male engagement on the Egesa program, men came to

the clinic to talk to her.

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Pricing of commodities and client incentives

Interventions in the public sector generally provide contraceptives free to clients,

however some facilities charge a consultation fee. The private sector does not have

regulated prices. One of the elements of the AMUA social franchising network was to

establish recommended prices for methods provided by the franchises. Tubal ligations are

provided free of charge as part of the Marie Stopes Kenya mobile TL outreach. This is

seen as particularly valuable to clients and providers, who report that having to pay for

TL is a hardship. As a 24-year-old mother of five said, “I wanted to go to town [for TL],

but there was no money. That’s when I heard from [the] doctor’s wife that there were

doctors from Nairobi coming to give this service here. So God helped me to come here

instead of town. For there was no money and the doctors wanted no money…so I came

here.” Some AMUA facilities also ran “Free IUCD Weeks,” which providers said helped

to build a buzz around the method and, at the same time, recruited clients to their clinics

who would then come back for other services.

The AMKENI project provided transport compensation for clients seeking sterilization

services. Although the uptake of the service increased under AMKENI, some

stakeholders were critical because the MOH could not sustain such a practice. One

respondent in Coast Province noted: “... we were giving [the clients] lunch and taking

them back home, so the moment the funding for the project ended, [clients] did not come.

So there is no way the Ministry of Health could have continued with that, because that is

not how we operate. So, we need to change that. I think now if we need to re-do it … we

need to change the focus and try to make the population and the public understand and

appreciate the service so that [the clients] can come out for the service.”

Promising directions for future LAPM interventions

Despite limitations, the interventions were successful in providing LAPM to some

clients. In-depth interviews with some of those LAPM users helped understand why they

made the choice to use LAPM, and how best to promote these methods in the future. For

LAPM users, the long-acting effectiveness or permanence of the methods is important.

Some users emphasized the convenience of not having to make repeated trips to the

clinic. For example, one 22-year-old mother of two said, “If I compare with other

methods I have used or heard about, I think this method [implant] is good because it’s

unlike the injectable…which you’ve [got] to keep coming for re-supply. This one you

stay for a long time without coming to [a] facility unless you’re experiencing side

effects.” Other users said they prefer long-acting methods because they don’t have to

remember to take pills every day, or remember to come back for re-injection.

Some users noted the lower costs associated with using a long-acting method. For

example, a 44-year-old mother of four said, “This [TL] is a good method which is cheap

— about one hundred shillings only, and then the hospital helped. This is done once and

that is all, expenses [are] less and [it] is a sure method.” Interestingly, although these

methods are perceived by some users as saving them money, some providers felt that

providing LAPMs was expensive in terms of both time and resources expended. This is

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despite the fact that frequent resupply visits by short-acting methods may in the end make

those methods more time intensive for providers.

Clients reported that undertaking TL is based on whether she believes she already has

enough children. Many IUCD and implant users said that once they had achieved their

desired number of children, they would be happy to switch to TL and have worry-free

protection from pregnancy. However, some women said they would never be ready to

make such a permanent decision. As one 33-year-old mother of two expressed, “I cannot

use [TL] because anything can happen. You know, these marriages are not permanent,

and one can divorce and get re-married. Then, my husband can want another child with

him, what will I do? You know you can get a man who looks after you ‘like an egg,’ and

he says he can give you the world as long as you give him a child. What will you do?

And you have done permanent FP, what will happen? You would have lost (laughs).”

Latent demand for TL

While overall use of TL has declined in Kenya, many providers interviewed noted that

TL demand was strong and increasing in their facilities. The AMUA project reports that

acceptance of TL is 30 percent higher than acceptance of IUCD. An AMUA in-charge

said, “Back in the year 2004, I could not see anyone go for tubal ligation, but now I am

able to send about 10 clients.” The ACQUIRE project observed a 20-percent increase of

TL in the Kisii District, even though the focus of the intervention was on IUCD. The

increase of TLs provided in the AMKENI project was twice as high as the increase in

IUCDs. Current LAPM clients seemed to have a good impression of female sterilization

overall, and many indicated that it would be their preferred method of contraception once

they had “enough” children. Over one-third of general FP clients also expressed

favorable opinions about TL, but another 20 percent said they didn’t know about the

method.

Despite the demand for TL, interventions have faced challenges in increasing access to

permanent methods of contraception. Among the facilities included in this assessment,

only about half offer TL and/or vasectomy services, although some of those facilities do

not have the surgical infrastructure to provide TL. The 2004 Kenya service provision

assessment found that only 46 percent of hospitals in Kenya offer female

sterilization.{#139} The AMUA project was unable to recruit medical doctors to its

network who would be able to furnish clients with TL services, so it had to rely on

mobile TL services. Mobile TL services have been successful in providing thousands of

women with TL in the past few years. Although this model of service provision requires

resources beyond those typically available in fixed clinical settings, it is unclear whether

training providers in static services and maintaining their surgical facilities would be

more cost-effective.

Conclusion

The interventions examined lasted from two to five years, and attempted to address

significant issues with health systems and entrenched attitudes among providers and

clients. A reversal of a decade-long trend of IUCD decline was not expected. Although

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all three projects made progress, the magnitude of progress, in terms of the total number

of clients served was relatively modest, compared to the total number of FP clients.

Medium-term outcomes were mixed. In the case of AMKENI, cessation of project

activities appears to have coincided with rapid returns to near-baseline levels of method

provision. This failure to sustain progress could be due to staff transfers and to logistical

problems with equipment, supplies, and commodities. On the other hand, the ACQUIRE

project observed continuing increases in IUCD service provision several months after the

project concluded. Still in progress, AMUA has increased and maintained its increase of

LAPM provision. Regardless of how the intervention performed, they all had challenges

with training, readiness of facilities in terms of equipment and commodities, and demand

creation. One single element did not stand out as the most important determinant of

increased LAPM uptake.

The assessment observed that staff transfers can have a dramatic impact on the effect of

an intervention in its target sites. Program managers reported that staff members who

were trained on LAPMs as part of an intervention were often transferred, leaving few or

no trained providers in their facilities. Programs need to have a greater commitment to

maintaining access to services through maintenance of a trained workforce. Two

approaches should be investigated:

Mechanisms for improved management of human resources should be instituted,

including better oversight of transfers and identification of replacement staff that have

LAPM skills and/or systems for continual training.

The MOH should experiment with mobile services, investing training dollars into

transportation and support of experienced providers who can extend services to

various sites. A cost effectiveness comparison of these two approaches would provide

better direction as to how the MOH can maintain a trained LAPM workforce.

This comparative assessment has shown that while the availability of supplies can be

improved through these interventions, once the project is ended, there appears to be a

rapid decline in supply assurance for both commodities and equipment. What innovative

approaches can the MOH use to improve logistic systems for LAPMs? Should the

MOH revisit the idea of socially marketing IUCD or implant kits? Alternatively, would

moving to a mobile system of LAPM services improve supply issues? The MOH should

continue its efforts to build systems that ensure method choice in all facilities.

Despite the extensive informational and demand creation efforts, significant gaps in client

knowledge about LAPMs remain. Beyond community-level communication efforts,

clients consistently say that their choice of method is influenced by their provider.

Accordingly, a concerted effort was made to educate providers about LAPMs,

particularly the IUCD, but negative attitudes persist. Some providers, for example, still

have inaccurate beliefs about whether the IUCD is appropriate for nulliparous or young

women, and unnecessary concerns about pelvic infections. In addition, the few reports

from clients and providers of the IUCD being ineffective for preventing pregnancy may

point to both problems with the quality of insertions and persistent myths and

misconceptions. Lack of belief in the effectiveness of IUCDs among providers is of

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particular concern since we know that providers influence client selection of methods,

and LAPM clients cite the effectiveness of these methods as one of their key advantages.

Several providers and program managers also reported that many men and women still

oppose vasectomy because they equate it with castration. Although the exact reason is

unknown, 34-percent of clients did report negative opinions about vasectomy. Erroneous

beliefs about vasectomy, such as that it is similar to castration, need to change if the

number of men choosing this highly effective method is ever to increase. Some of these

biases against LAPMs may explain why, according to clients, providers counseled about

IUCDs, TL and vasectomy in less than half of their client interactions.

While each of these interventions included some level of demand creation, the approach

and intensity of demand creation activities differed significantly. In particular, the

ACQUIRE project focused on method-specific marketing efforts and used mass media

channels, while the AMKENI project and AMUA Network undertook more general FP

BCC/IEC efforts. The cost and impact of these approaches differed and need to be

examined to determine their potential cost-effectiveness and sustainability. The broader

IEC messages appeared to be less effective than targeted messages, though political

sensitivities did exist early on regarding method-specific promotions. A key question that

remains is what level of effort is needed with respect to marketing, and how often do

media campaigns need to be repeated. Is there a “tipping point” in marketing when

advertising can be said to be effective?

CBD agents seemed to play a key role in education and referral to clinics, but retaining

committed volunteers over time is challenging. Although donors and MOH personnel

noted the importance of demand creation activities, and urged providers to do more

community outreach regarding LAPM, many facility managers said that they lack the

resources (staffing and monetary resources) to accomplish this. Community mobilization

activities must address the volunteers’ own needs, the most important being economic

survival. It may be cost-effective to maintain a core of highly motivated, effective

volunteers by providing them with regular incentives rather than constantly training new

volunteers, but funding for volunteer incentives is rarely available. The AMUA project

gives KSh.100 for every client a CBD refers to one of their network facilities. This

practice may not be feasible outside the private sector, but needs to be explored further.

According to conversations with staff members, AMKENI’s experience suggests that

incentives do not have to take the form of a regular salary, nor do they need to be costly.

Items such as uniforms (i.e., t-shirts, caps), badges, opportunities to participate in

workshops, certificates of attendance at training courses, and the opportunity to

participate in income-generating activities are also highly motivating. Strategies for how

these CBD agents can be further leveraged while providing a mechanism for

incentives to strengthen their commitment and retention could be investigated more

widely.

Implementing both supply-side and demand-side activities at the same time as conducting

advocacy, which all three interventions did, appears to be a good model as long as supply

is in place before demand is created. However, the medium-term results of the projects

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were mixed. ACQUIRE, an intervention targeted at one method, seemed to yield more

positive results, but the costs involved in such a project need to be examined. In fact, the

costs associated with either targeted IUCD or broader LAPM/FP interventions have not

been closely examined, thus information on cost per CYP, replicability, and sustainability

is lacking. Filling this knowledge gap should be a priority, as it will be important

information for policy makers when deciding where to invest their limited resources. It

will also be important to follow the work of the AMUA project over time, as a social

franchising network of private providers may be a promising direction for future public-

private partnership efforts, especially if its costs decrease over time allowing for a greater

potential for sustainability. Instead of primarily relying on donor funds, LAPM efforts

should be mainstreamed into the MOH structure and funded through the annual operating

plans (AOP). Finally, if they decide that LAPM efforts should continue to be prioritized,

the MOH and donors need to take a long-term approach to promoting LAPM utilization

so that progress achieved during interventions can be sustained over time.

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Appendix: Documents Reviewed

EngenderHealth. The AMKENI Project, January 1, 2001 to June 30, 2006 : End-of-

Project Report. New York

EngenderHealth. The story so far: Practical experience, lessons learned and the way

forward. The AMKENI Project Report, 2005

Smith, A., Pile J.M., Ndede, F., Escandon, I. Revitalizing Family Planning in Kisii

District, Kenya: Increasing Awareness, Access and Use of the IUCD Through Supply,

Demand and Advocacy (draft), October 2007.

Griffith, D., Ahmed, R., Milutinovic, M. Social Franchising Project for Modern Clinical

Family Planning Methods (AMUA). Midterm Review Report, 2005.

Ngom P., H. Tucker, E. Wong, M. Kuyoh, N. Maggwa. Impact of AMKENI on Family

Planning and Reproductive Health Behavior: 2001-2004. Family Health International

2005

Njue, C. Stakeholder analysis report for A Comparative Assessment of Long-acting and

Permanent Methods (LAPM) Interventions in Kenya: 2001-2006, 2007.

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