Towards achieving the family planning targets in the African region: a rapid review of task sharing policies.

BACKGROUND: Expanding access and use of effective contraception is important in achieving universal access to reproductive healthcare services, especially in low- and middle-income countries (LMICs), such as those in sub-Saharan Africa (SSA). Shortage of trained healthcare providers is an important contributor to increased unmet need for contraception in SSA. The World Health Organization (WHO) recommends task sharing as an important strategy to improve access to sexual and reproductive healthcare services by addressing shortage of healthcare providers. This study explores the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries. This evidence is aimed at promoting the implementation and scale-up of task sharing programmes in SSA countries by WHO. METHODOLOGY AND FINDINGS: We employed a rapid programme review (RPR) methodology to generate evidence on task sharing for family planning programmes from five SSA countries namely, Burkina Faso, Cote d'Ivoire, Ethiopia, Ghana, and Nigeria. This involved a desk review of country task sharing policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, WHO regional meeting reports on task sharing for family planning; and information from key informants on country background, intervention packages, impact, enablers, challenges and ways forward on task sharing for family planning. The findings indicate mainly the involvement of community health workers, midwives and nurses in the task sharing programmes with training in provision of contraceptive pills and long-acting reversible contraceptives (LARC). Results indicate an increase in family planning indicators during the task shifting implementation period. For instance, injectable contraceptive use increased more than threefold within six months in Burkina Faso; contraceptive prevalence rate doubled with declines in total fertility and unmet need for contraception in Ethiopia; and uptake of LARC increased in Ghana and Nigeria. Some barriers to successful implementation include poor retention of lower cadre providers, inadequate documentation, and poor data systems. CONCLUSIONS: Task sharing plays a role in increasing contraceptive uptake and holds promise in promoting universal access to family planning in the SSA region. Evidence from this RPR is helpful in elaborating country policies and scale-up of task sharing for family planning programmes.

RESUME: INTRODUCTION: L'élargissement de l'accès et de l'utilisation d'une contraception efficace est important pour parvenir à l'accès universel aux services de santé reproductive, en particulier dans les pays à revenu faible et intermédiaire, comme ceux de l'Afrique subsaharienne. L'insuffisance de prestataires de soins de santé qualifiés est un facteur important de l'augmentation des besoins non satisfaits en matière de contraception en Afrique subsaharienne. L'Organisation mondiale de la Santé (OMS) recommande le partage des tâches comme stratégie importante pour améliorer l'accès aux services de santé sexuelle et reproductive en s'attaquant à la pénurie des prestataires de soins de santé. Cette étude explore l'état des lieux, les réussites, les défis et les impacts de la mise en œuvre du partage des tâches pour la planification familiale dans cinq pays d'Afrique subsaharienne. Ces données factuelles visent à promouvoir la mise en œuvre et l'extension des programmes de partage des tâches dans les pays d'Afrique sub-saharienne par l'OMS. MéTHODOLOGIE ET RéSULTATS: Nous avons utilisé la méthodologie de la revue rapide des programmes (RPR) pour générer des données sur le partage des tâches pour les programmes de planification familiale de cinq pays d'Afrique subsaharienne, à savoir le Burkina Faso, la Côte d'Ivoire, l'Éthiopie, le Ghana et le Nigéria. Cela impliquait la revue documentaire des documents de politique nationale de partage des tâches, des plans de mise en œuvre et des directives, des rapports annuels sur les programmes de santé sexuelle et reproductive, des rapports des réunions régionales de l'OMS sur le partage des tâches pour la planification familiale; et des informations provenant des informateurs clés sur le contexte du pays, les programmes d'intervention, l'impact, les catalyseurs, les défis et les voies à suivre pour le partage des tâches pour la planification familiale. Les résultats indiquent principalement l'implication des agents de santé communautaires, des sages-femmes et des infirmières dans les programmes de partage des tâches avec une formation liée à l'approvisionnement de pilules contraceptives et de contraceptifs réversibles à longue durée d'action (LARC). Les résultats indiquent une augmentation des indicateurs de planification familiale pendant la période de mise en œuvre du partage des tâches. Par exemple, l'utilisation des contraceptifs injectables a plus que triplé en six mois au Burkina Faso; le taux de prévalence de la contraception a doublé avec une baisse de la fécondité totale et des besoins non satisfaits en matière de contraception en Éthiopie; et l'adoption du LARC a augmenté au Ghana et au Nigéria. Certains obstacles à la réussite de la mise en œuvre comprennent une faible rétention des prestataires de niveau inférieur, une documentation inadéquate et des systèmes peu performants de gestion des données. CONCLUSIONS: Le partage des tâches joue un rôle important dans l'augmentation de l'utilisation de la contraception et dans la promotion de l'accès universel à la planification familiale dans la région Afrique subsaharienne. Les données de ce RPR sont utiles pour l'élaboration des politiques nationales et l'intensification du partage des tâches pour les programmes de planification familiale. Correct and consistent use of contraceptives has been shown to reduce pregnancy and childbirth related maternal deaths and generally improve reproductive health. However, statistics show that many women of reproductive age in SSA who ought to be using contraceptives are not using them. As a result, high rates of maternal deaths from pregnancy or childbirth-related complications have been recorded in the region. One of the key barriers to accessing family planning in SSA is the shortage of healthcare providers. To address this problem, WHO recommends task sharing as an intervention to improve access and use of sexual and reproductive health services including family planning. While task sharing guidelines have been developed and disseminated in many SSA countries, limited evidence exists on their adoption, implementation and outcomes to promote scale-up. This study undertook a rapid programme review of evidence from policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, regional meeting reports and key stakeholder reports on task sharing to explore the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries: Burkina Faso, Cote d'Ivoire, Ethiopia, Ghana, and Nigeria. We found that task sharing programmes mainly involved community health workers, midwives and nurses. The intervention led to increased modern contraception access and use and general improvement in family planning indicators during the implementation periods. Some barriers to successful implementation of task sharing include poor retention of lower cadre providers, inadequate documentation, and poor data systems.

Sub-Saharan Africa and the health MDGs: the need to move beyond the "quick impact" model.

The Millennium Development Goals (MDGs) were defined in 2001, making poverty the central focus of the global political agenda. In response to MDG targets for health, new funding instruments called Global Health Initiatives were set up to target specific diseases, with an emphasis on "quick win" interventions, in order to show improvements by 2015. In 2005 the UN Millennium Project defined quick wins as simple, proven interventions with "very high potential short-term impact that can be immediately implemented", in contrast to "other interventions which are more complicated and will take a decade of effort or have delayed benefits". Although the terminology has evolved from "quick wins" to "quick impact initiatives" and then to "high impact interventions", the short-termism of the approach remains. This paper examines the merits and limitations of MDG indicators for assessing progress and their relationship to quick impact interventions. It then assesses specific health interventions through both the lens of time and their integration into health care services, and examines the role of health systems strengthening in support of the MDGs. We argue that fast-track interventions promoted by donors and Global Health Initiatives need to be complemented by mid- and long-term strategies, cutting across specific health problems. Implementing the MDGs is more than a process of "money changing hands". Combating poverty needs a radical overhaul of the partnership between rich and poor countries and between rich and poor people within countries.

The national subsidy for deliveries and emergency obstetric care in Burkina Faso.

INTRODUCTION: To reduce financial barriers to health care services presented by user fees, Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policy's entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government, three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently, before all the technical instruments were ready. The subsidy is paid by the national budget (US$60 million, including US$10 million for the worst-off). Information activities, implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information, such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population, but there has been no attempt to impede the policy's implementation. At the time of the study, fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policy's introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls, health workers have figured out how to take advantage of the system. Some of the policy's instruments should be reviewed and clarified to improve its effectiveness.

Factors predicting uptake of voluntary counselling and testing in a real-life setting in a mother-and-child center in Ouagadougou, Burkina Faso.

OBJECTIVE: To identify factors predicting uptake of voluntary HIV counselling and testing in pregnant women. METHODS: All pregnant women receiving ante-natal group health education at St Camille Medical Center, Ouagadougou, Burkina Faso from 1 May 2002 to 30 April 2004 were offered voluntary HIV counselling and testing. If they consented, the women were pre-test counselled, tested by two rapid tests giving immediate results and post-test counselled. RESULTS: Less than one-fifth of pregnant women [1,216/6,639 (18.3%, CI 17.4-19.3%)] accepted voluntary HIV counselling and testing, mainly at the first ante-natal visit (83.4%) and at early gestational age (73.4% before week 24). The HIV seroprevalence rate was 10.6% (8.8-12.5%). The uptake rate was independently associated with age, the number of previous pregnancies and the number of previous miscarriages. CONCLUSIONS: Our two-step approach of group education followed by voluntary HIV counselling and testing yielded a low uptake rate in this setting. However, the drop-out rate after enrolling in the programme was nearly zero. The timing of programme uptake would permit implementation of earlier prophylactic courses. Effective scaling-up of voluntary HIV counselling and testing outside the clinical trial requires a mass sensibilization campaign pointing out the programme's benefits and addressing the stigma of HIV. The independent value of age and previous obstetrical episodes show how important social factors are in influencing the voluntary HIV counselling and testing uptake rate.