Advocacy as a Tool for Advancing Family Planning in the Democratic Republic of the Congo: A Case Study.

The national strategic plan for family planning (FP) in the Democratic Republic of the Congo (DRC) calls for an increase in modern contraceptive prevalence in 2025. The DRC's size and weak health infrastructure pose significant challenges to programming in all areas of primary health care, including FP. Notwithstanding, in the past decade, a group of advocates organized to undertake a series of activities to improve the policy environment for FP in the DRC. We outline the 4 major accomplishments to date: revitalizing a multisectoral FP stakeholder group at the national and provincial levels, obtaining the repeal of the Law of 1920 in the form of a new Public Health Law passed in 2018, soliciting public statements favorable to FP from political figures including 2 presidents, and securing the disbursement of government funds for the purchase of contraceptives. We reveal the work behind the scenes needed to obtain these advocacy wins. Given that the field of advocacy does not lend itself to rigorous evaluation using randomized trials or quasi-experimental design, it is important to document and analyze how such advocacy wins can be attained.

The scale-up and integration of contraceptive service delivery into nursing school training in the Democratic Republic of the Congo.

In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools.

An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa.

OBJECTIVES: Given the promise of DMPA-SC to increase community-level access to modern contraception in developing countries, we conducted an observational study to assess the acceptability and feasibility of DMPA-SC self-injection among women in Kinshasa, Democratic Republic of the Congo, and of medical/nursing (M/N) students as instructors for self-injection. STUDY DESIGN: Women who selected DMPA-SC at a community outreach event adjacent to a health center were interviewed upon acceptance (baseline) and then 3, 6 and 12 months later. RESULTS: Of 850 clients selecting DMPA-SC at baseline, 640 (75.3%) opted for self-injection over being injected by the M/N students for reasons of convenience and personal agency. Among these 640 self-injectors, 47.5% were anxious at baseline (for fear of needles or injecting incorrectly). Over 80% reported feeling very ready after training, confident that they knew how to self-inject and confident that they would remember the next injection date. By 3 months, 97% described it as easy. Half (54%) experienced side effects, mainly menstrual irregularities, the main reason for discontinuation. At 6-month follow-up, self-injectors cited effectiveness and ease of use as positive elements, though one quarter reported side effects. Their impressions of M/N students as instructors were highly positive. CONCLUSIONS: Where DMPA-SC was free and easily accessible, the majority of women interested in DMPA-SC opted to learn self-injection. The M/N students performed well in instructing women to self-inject. Clients were highly satisfied with the services received, yet many did not recognize their student status, possibly because outreach occurred near a health facility. Once told, clients remained very favorable, suggesting strong motivation to receive their preferred contraceptive free, whoever the provider. IMPLICATION STATEMENT: This study provides additional evidence on the acceptability and the feasibility of the self-injection of DMPA-SC by users from a resource-limited setting.

Family Planning in the Democratic Republic of the Congo: Encouraging Momentum, Formidable Challenges.

Momentum for family planning in the Democratic Republic of the Congo (DRC) is evident in multiple ways: strong political will, increasing donor support, a growing number of implementing organizations, innovative family planning programming, and a cohesive family planning stakeholder group. Between 2013 and 2017, the modern contraceptive prevalence rate (mCPR) in the capital city of Kinshasa increased from 18.5% to 26.7% among married women, but as of 2013-14, it was only 7.8% at the national level. The National Multisectoral Strategic Plan for Family Planning: 2014-2020 calls for achieving an mCPR of 19.0% by 2020, an ambitious goal in light of formidable challenges to family planning in the DRC. Of the 16,465 health facilities reporting to the national health information system in 2017, only 40% offer family planning services. Key challenges include uncertainty over the political situation, difficulties of ensuring access to family planning services in a vast country with a weak transportation infrastructure, funding shortfalls for procuring adequate quantities of contraceptives, weak contraceptive logistics and supply chain management, strong cultural norms that favor large families, and low capacity of the population to pay for contraceptive services. This article describes promising initiatives designed to address these barriers, consistent with the World Health Organization's framework for health systems strengthening. For example, the national family planning coordinating mechanism is being replicated at the provincial level to oversee the expansion of family planning service delivery. Promising initiatives are being implemented to improve the supply and quality of services and generate demand for family planning, including social marketing of subsidized contraceptives at both traditional and non-traditional channels and strengthening of services in military health facilities. To expand contraceptive access, family planning is being institutionalized in nursing schools, allowing students to operate as community-based distributors. While major challenges remain, significant progress in family planning has been made in the DRC, which should be judged not in comparison with sub-Saharan African countries with high mCPR and mature programs, but rather with those starting from much further behind.

Getting to FP2020: Harnessing the private sector to increase modern contraceptive access and choice in Ethiopia, Nigeria, and DRC.

BACKGROUND: An estimated 214 million women have unmet need for family planning in developing regions. Improved utilization of the private sector is key to achieving universal access to a range of safe and effective modern contraceptive methods stipulated by FP2020 and SDG commitments. Until now, a lack of market data has limited understanding of the private sector's role in increasing contraceptive coverage and choice. METHODS: In 2015, the FPwatch Project conducted representative outlet surveys in Ethiopia, Nigeria, and DRC using a full census approach in selected administrative areas. Every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, availability, and price. FINDINGS: Excluding general retailers, 96% of potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods available. In Ethiopia, 41% of modern contraceptive stocking outlets were in the private sector compared with approximately 80% in Nigeria and DRC where drug shops were dominant. Ninety-five percent of private sector outlets in Ethiopia had modern contraceptive methods available; 37% had three or more methods. In Nigeria and DRC, only 54% and 42% of private sector outlets stocked modern contraceptives with 5% and 4% stocking three or more methods, respectively. High prices in Nigeria and DRC create barriers to consumer access and choice. DISCUSSION: There is a missed opportunity to provide modern contraception through the private sector, particularly drug shops. Subsidies and interventions, like social marketing and social franchising, could leverage the private sector's role in increasing access to a range of contraceptives. Achieving global FP2020 commitments depends on the expansion of national contraceptive policies that promote greater partnership and cooperation with the private sector and improvement of decisions around funding streams of countries with large populations and high unmet need like Ethiopia, Nigeria, and DRC.

Acceptability of the community-level provision of Sayana® Press by medical and nursing students in Kinshasa, Democratic Republic of the Congo.

OBJECTIVES: The objectives were to assess acceptors' attitudes toward Sayana® Press as a method and toward the mechanism of community-based distribution by medical and nursing (M/N) students, known locally as "DBCs," in Kinshasa, Democratic Republic of the Congo, and to evaluate the experience of these DBCs. STUDY DESIGN: In 2015, surveys were conducted among (1) acceptors of Sayana® Press on the day of the initial injection, (2) these same acceptors 3 months later and (3) the DBCs providing community-based services. The analysis was descriptive and involved no significance testing. RESULTS: Acceptors of Sayana® Press expressed high levels of satisfaction with the method, despite some pain experienced at injection and subsequent side effects. Although most were satisfied with the counseling and services received from the DBCs, less than one third realized that the providers were M/N students. The DBCs expressed satisfaction in serving as community-based distributors; more than 95% would recommend it to others. Their primary complaints were lack of remuneration, stockouts and need for greater supervision. CONCLUSIONS: Consistent with results from previous pilot introductions of Sayana® Press in three African countries, clients were highly satisfied with Sayana® Press as a method. The reported preference for resupply at health centers may reflect a lack of client awareness that the DBCs administering methods near the health center were not in fact staff from the health center. The pilot served to gain acceptance for the use of M/N students in community-based distribution, paving the way for additional task-shifting pilots in Kinshasa. IMPLICATIONS: Sayana® Press represents a promising new method for increasing access to modern contraception in low-income countries. The Kinshasa experience is the first to test the use of medical and nursing students as providers at the community level. The study reports high levels of satisfaction on three counts: acceptors of the contraceptive method, acceptors of the mode of service delivery, and DBCs in their role as providers of contraception at the community level. However, many clients were not aware that the DBCs were students. The study represents an important contribution to the literature on task-shifting, especially in a country with chronic shortages of healthcare personnel.

Pilot Research as Advocacy: The Case of Sayana Press in Kinshasa, Democratic Republic of the Congo.

In the Democratic Republic of the Congo (DRC), the Ministry of Health authorizes only physicians and nurses to give injections, with one exception-medical and nursing students may also give injections if supervised by a clinical instructor. The emergence of the injectable contraceptive Sayana Press in some African countries prompted the DRC to test the acceptability and feasibility of distributing Sayana Press and other contraceptive methods at the community level through medical and nursing students. Sayana Press is similar in formulation to the injectable contraceptive Depo-Provera but contains a lower dose and is administered subcutaneously using a single-use syringe with a short needle called the Uniject system. The Uniject system allows Sayana Press to be administered by community health workers without clinical training or by self-injection. In this pilot, the advocacy objective was to obtain approval from the Ministry of Health to allow medical and nursing students to inject Sayana Press, as a first step toward authorization for community health workers to provide the method. The pilot described in this article documents a process whereby an innovative approach moved from concept to implementation to replication in less than 2 years. It also paved the way for testing additional progressive strategies to increase access to contraception at the community level. Because the pilot project included a research component designed to assess benefits and challenges, it provided the means to introduce the new task-shifting approach, which might not have been approved otherwise. Key pilot activities included: (1) increasing awareness of Sayana Press among family planning stakeholders at a national conference on family planning, (2) enlisting the support of key decision makers in designing the pilot, (3) obtaining marketing authorization to distribute Sayana Press in the DRC, (4) implementing the pilot from July to December 2015, (5) conducting quantitative and qualitative studies to assess acceptability and feasibility, and (6) disseminating the findings to family planning stakeholders. Before the pilot, Sayana Press was relatively unknown in the DRC, and there was no precedent for medical and nursing students providing family planning methods or giving injections at the community level. In less than 12 months, the approach gained legitimacy and acceptance. The key Ministry of Health decision maker orchestrated the closing session of the dissemination meeting on next steps, paving the way for pilot tests of 3 new task-shifting approaches: insertion of Implanon NXT by medical and nursing students, self-injection for Sayana Press with supervision by students, and injection of Sayana Press by community health workers with no formal clinical training.

Family Planning Policy Environment in the Democratic Republic of the Congo: Levers of Positive Change and Prospects for Sustainability.

Building on expressed support from the Prime Minister to the Ministries of Health and Planning, the country's new family planning commitment grew out of: (1) recognition of the impact of family planning on maternal mortality and economic development; (2) knowledge sharing of best practices from other African countries; (3) participatory development of a national strategic plan; (4) strong collaboration between stakeholders; (5) effective advocacy by champions including country and international experts; and (6) increased donor support. The question becomes: Will the favorable policy environment translate into effective local programming?

Family Planning Supply Environment in Kinshasa, DRC: Survey Findings and Their Value in Advancing Family Planning Programming.

BACKGROUND: Modern contraceptive prevalence was 14.1% in 2007 in Kinshasa, the capital city of the Democratic Republic of the Congo (DRC). Yet virtually nothing was known about the family planning supply environment. METHODS: Three surveys of health facilities were conducted in 2012, 2013, and 2014 to determine the number, spatial distribution, and attributes of sites providing family planning services. The 2012 and 2013 surveys aimed to identify the universe of family planning facilities while obtaining a limited set of data on "readiness" to provide family planning services (defined as having at least 3 modern methods, at least 1 person training in family planning in the last 3 years, and an information system to track distribution of products to clients) and output (measured by couple-years of protection, or CYP). In contrast, the 2014 survey, conducted under the umbrella of the Performance Monitoring and Accountability 2020 (PMA2020) project, was based on 2-stage cluster sampling. This article provides detailed analysis of the 2012 and 2013 surveys, including bivariate and multivariate analysis of correlates of readiness to provide services and of output. RESULTS: We identified 184 health facilities that reported providing at least 1 contraceptive method in 2012 and 395 facilities in 2013. The percentage of sites defined as "ready" to provide services increased from 44.1% in 2012 to 63.3% in 2013. For the 3-month period between January and March 2013, facilities distributed between 0 and 879.2 CYP (mean, 39.7). Nearly half (49%) of the CYP was attributable to implants, followed by IUDs (24%), CycleBeads (11%), and injectables (8%). In 2013, facilities supported by PEPFAR (n = 121) were more likely than other facilities to be rated as ready to provide services (P<.0001); however, PEPFAR-supported sites generated less CYP on average than sites supported by family planning implementing agencies (P<.0001). Multivariate analysis showed 3 variables were associated with CYP: type of health facility, length of time in operation, and number of contraceptive methods available. Clinics generated higher (3-month) CYP than hospitals and health centers by 65.3 and 61.5 units, respectively (P<.01). The mean CYP for facilities in operation for 4-6 years was 26.9 units higher (P<.05), and 50.2 units higher for those operating 7+ years (P<.01), than the reference group of facilities in operation for 1 year or less. For each additional method available at a facility, CYP increased by almost 8 units (P<.01). CONCLUSIONS: Findings from these surveys suggest that lack of physical access is not the defining reason for low contraceptive use in Kinshasa, although it is highly likely that other service-related factors contribute to low service utilization. The results contributed to increasing the momentum for family planning in the DRC in many ways, including mobilizing partners to increase contraceptive access and increasing donor investment in family planning in the DRC.