SPOTLIGHT
In Mali CBD Helps People Continue Family Planning
In Mali a community-based distribution (CBD) project helped expand the reach of family planning and ensure that contraceptive users could continue to have access to supplies and good-quality services. The project demonstrates how CBD can play a key role in a continuing-client strategy where unmet need for family planning is substantial and access to good-quality services is limited.
In 1998 some 2,000 trained CBD workers began providing family planning services to underserved rural communities in five regions of the country. They counseled and supplied continuing clients who previously lacked a reliable source of contraceptive methods, and also attracted new clients who had been unable to adopt family planning. The project, an initiative of Save The Children, a non-profit organization working in over 40 countries worldwide, was funded by USAID and involved Malian non-governmental organizations (NGOs), which provided support and supplies to the CBD workers (75).
The project aimed to achieve contraceptive prevalence of 50% among women of reproductive age who had a child two years of age or younger and who did not want to have another child for at least two years. This goal was met or exceeded in 13 out of 17 project areas, and overall contraceptive prevalence among this group of women in the program areas was estimated at 69% in 2002, more than twice the level of 29% in 1998.
CBD Improves Rural Access
In Mali many rural people face long trips to towns where pharmacies, shops, and clinics provide contraceptive methods. Most people cannot afford to make the trip. Even women who could afford to travel often have too many domestic responsibilities to even consider the trip. Thus many who adopt contraception are unable to continue using it for long.
The CBD project helped overcome these barriers. CBD workers who lived in the community provided counseling, screening, and referrals, as well as supplying contraceptives, to enable clients to initiate and continue contraceptive use. Women who previously had little or no access to services could now receive them at home, or at weekly women's group meetings.
Others who were reluctant or embarrassed to ask for contraceptives at health centers or pharmacies could obtain condoms and other supply methods from the CBD workers. Also, clients who preferred to use contraceptives clandestinely could obtain OCs discreetly from CBD workers. Some married women use OCs without their husband's knowledge or support and often must interrupt or discontinue use entirely when they cannot find a way to resupply privately. Similarly, men and unmarried young people often prefer to obtain condoms discreetly.
CBD workers improved access both by reducing the costs of obtaining family planning methods and by providing flexible payment options. For many people, the cost of transportation to a health clinic or pharmacy is a substantial barrier to sustained contraceptive use. In the project areas clients could avoid transportation costs, as well as save the time required to make the journey, by choosing to visit the CBD distributors in their communities.
Additionally, CBD workers permitted clients to obtain contraceptives on credit, to pay in installments, or to pay in kind (for example, with chickens or peanuts), rather than in cash. The CBD agents established trusting relationships with clients that allowed them to extend credit, which was unavailable through pharmacies or health centers.
CBD Strengthens Client-Provider Relationships
CBD workers visited women in their homes initially to establish good relationships with new clients and then made follow-up visits to build a continuing relationship. A person who was considering adopting family planning often would hear about the family planning services at community meetings or at educational entertainment events organized by CBD workers and could arrange an initial home visit with a worker.
During this initial visit, the fieldworker explained the contraceptive methods that were available, screened women for medical eligibility for certain methods, and helped them choose a method. During home visits clients could discuss their family planning preferences in private and ask questions without embarrassment. Clients who wanted OCs, condoms, or spermicides could purchase and learn how to use them directly from the CBD worker.
For clients who preferred to use injectables, IUDs, or implants, which required a clinic visit, the CBD workers provided referrals to nearby government health facilities. They often accompanied clients to their clinic appointments or, when unable to accompany a client, supplied a note to the health care provider explaining the reason for the appointment.
CBD workers helped clients continue using their chosen method by providing follow-up consultations. One week after beginning OC use, for example, a new client would receive a second consultation in a home visit by the CBD worker. The objective was to make sure that new clients were taking the pills consistently and correctly and to help clients manage common side effects that are not usually harmful but often lead to discontinuation.
CBD workers often visited the homes of continuing clients who were regular OC users two days before their monthly pack of pills was finished to remind them that it was time to get a new pack. If the client did not buy the new cycle of pills on or before the date needed, the CBD worker made another home visit. This type of individual follow-up began spontaneously, initiated by the CBD workers themselves.
The CBD workers succeeded in making family planning part of the everyday experience of the project communities. In some communities contraceptive acceptability and access increased greatly, and local stores began to sell contraceptive products, sometimes to the point where the CBD approach was no longer necessary. In other communities CBD agents continue to provide clients with contraceptive supplies, supported by local NGOs. In still others, CBD workers continue their involvement but with less project supervision and less access to supplies.
Sources: Cissé 2005 (26), Leonard 2002 (75), Mwebesa 2006 (91)
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