Abstract
In a context where distance, user fees, and health staff shortages constitute significant barriers to accessing facility-based family planning services, the use of community-based distributors (CBDs) as counseling and contraceptive providers has been tested in several resource-constrained environments to increase family planning uptake. In the capital city of the Democratic Republic of the Congo (DRC), Kinshasa, a massive CBD program (AcQual) has been implemented since 2014, with lackluster results measured in terms of the low volume of contraceptives provided. A process evaluation conducted in 2017 assessed the fidelity of implementation of the program compared with the original AcQual design and analyzed gaps in provider training and motivation, contraceptive supplies, and reporting and monitoring processes. Its objective was to identify both theory and implementation failures in order to propose midcourse corrections for the program. The mixed-method data collection focused on the CBDs as a pivotal component of the AcQual program with 700 active CBDs interviewed. In addition, 10 in-depth interviews were conducted with clinical personnel, local health program managers, and project partners to identify gaps in the AcQual implementation environment. Issues with CBDs' performance, knowledge retention, and commitment to program activities, as well as gaps in contraceptive supply chains and insufficient monitoring and supervision processes, were the main implementation failures identified. Inappropriate method mix offered by the CBDs (condoms, pills, and CycleBeads only) and chronic overburdening of health care staff at the local level compounded these issues and explained the low volume of contraceptives provided through AcQual. Midcourse corrections included a more structured schedule of activities, stronger integration of CBDs with clinical providers and health zone managers, expansion of the mix of contraceptives offered to include subcutaneous injectables and emergency contraceptive pills, and clarifying reporting and monitoring responsibilities among all partners. Findings from this process evaluation contribute to the limited knowledge base regarding "unwelcome results" by examining all the intervention components and their relationships to highlight areas of potential failures, both in design and implementation, for similar CBD programs.
Highlights
Planning need in the Democratic Republic of the Congo (DRC) and its capital, Kinshasa, are among the highest in the world
Of the 870 community-based distributors (CBDs) trained by AcQual partners since February 2014, 105 (12.1%) were no longer active, 65 (7.5%) were still active but refused to be interviewed, and 700 (80.5%) declared they were still active and consented to be interviewed
The number of days worked and CYPs distributed by active CBDs based on recall for the last month were low
Summary
Planning need in the Democratic Republic of the Congo (DRC) and its capital, Kinshasa, are among the highest in the world. Modern contraceptive prevalence remains low (7.8%).[1] In Kinshasa, the estimated unmet need for contraceptives among all women (i.e., the percentage of women who do not want another child for at least 2 years but are not currently using modern contraceptives) is 22.6%.2. This figure has been partially attributed to the lack of access to quality health facilities that can provide family planning services to women living in Kinshasa.
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