Family Planning Plus: Community-Based Family Planning System for Community Health Workers and Supervisors in Tanzania

Community-based family planning system, with multiple implementations, which supports community health workers and supervisors who provide family planning services in the community. This system follows the Balanced Counseling Strategy Plus and Tanzania guidelines.

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Contact

Rebecca Litner Email
Project Manager
Gloria Kahamba Email
Project Manager
D-tree International

Implementation Partners

D-tree International
Pathfinder International
Shirati KMT Hospital
Bruyere Research Institute
Rorya District CHMT

Funders

Bergstrom Foundation
Packard Foundation
USAID
International Development Research Center Canada

Implementation Dates

January 1, 2014 - November 30, 2020

Geographic Scope

Tanzania: Shinyanga, Mara, Arusha, Manyara, Kigoma, Katavi

Target Users

Client, Health Care Provider, Health System Manager, Data Services Provider

Enabling Environment Building Blocks

Services and Applications, Workforce

Family Planning Program Classification

Service Delivery

Introduction

Although family planning services in Tanzania are offered free of charge and citizens have a high awareness of contraceptive methods, uptake of family planning in Tanzania remains low. As of 2010, 24 percent of married women of reproductive age (MWRA) were using a contraceptive method with a total fertility rate (TFR) of 5.4. The situation is more pronounced in the rural Shinyanga region, where only 12.5 percent of MWRA are using a modern contraceptive method, total fertility rate is 7.1 and 22 percent of women have an unmet need for family planning, as well as in the Lake Zone region, where use of a modern contraceptive is 15 percent and the unmet need is 33 percent. The Lake Zone region also experienced more frequent stockouts of family planning commodities than elsewhere in Tanzania. 

One factor affecting initiation of contraception and continued use is satisfaction with family planning services, and studies have shown that the most common reason for discontinuation is dissatisfaction with the quality of family planning services.

Through eight years of developing and implementing family planning systems, D-tree International has worked to address this gap with a solution, Family Planning Plus (FP Plus), a comprehensive digital system supporting community-based family planning service provision, based on the Balanced Counselling Strategy Plus (BCS+). This solution has proved to be flexible and impactful, as it has been modified for different settings and has seen sustained positive program outcomes. We will reference three different implementations in this case study to show the evolution and impact of the solution. 

  1. The Shinyanga program, “Your decision, Your Tomorrow,” was implemented in 2014 and is still active, with funding from the Packard Foundation and implementation with Pathfinder International. Pathfinder International received funding from the Packard Foundation and chose to work with D-tree International to design and deploy the digital system that we now call FP Plus.
  1. The Shirati hospital program, implemented from 2017-2019 with International Development Research Center Canada funding and collaboration with Shirati KMT hospital and the Bruyere Research Institute. This program builds on the Shinyanga program, with additional reporting and motivation capabilities. It was implemented as part of a short-term research study of family planning perceptions and use before and after the two-year intervention period. 
  1. The Population Health and Environment program was implemented beginning in 2017 and is still active, with U.S. Agency for International Development funding and implementation collaboration with Pathfinder International. In addition to its original FP Plus functionality, this program includes a unique component related to first-time mothers and other community services.

Project/Digital Health Solution Overview

The digital solution, FP Plus, comprises two mobile applications (one for Community Health Workers or CHWs and one for supervisors), on-device reports for users to track their individual and program performance, and comprehensive program dashboards. The system applies to the continuum of family planning services, from CHW counselling with the client, to facility referrals and follow-up between the CHW and supervisor. The solution supports:

  • Offline case management and decision support.
  • Complex workflow, guiding systematic method choice, distribution, follow-up, and visit scheduling.
  • Referral coordination and tracking.
  • Health worker and supervisor motivation schemes, including pay-for-performance.
  • Citizen report card for client feedback and accountability.
  • Mobile supervisory systems with on-device reports (accessible offline) and the ability to send and receive messages within the team.
  • Stock reporting and tracking at the health facility.
  • Dashboards with government reports, program indicators, and dynamic analyses.
  • Data-sharing and integration with partner District Health Information Software-2 (DHIS-2) system.

At the core of this digital system is the CHW, guided by a mobile application with the Balanced Counseling Strategy + to help the CHWs organize and schedule the appropriate series of client interactions needed to ensure their needs are satisfied. The solution is flexible, as it can be configured for the program context and customized based on program needs and focus area. For instance, the system included enhanced reporting for the Shirati Hospital program and a unique first-time mother component for the Population Health and Environment program

Evaluation and Results Data

The original program in Shinyanga was implemented with 224 CHWs and 16 supervisors, and has served nearly 40,000 clients. This intervention resulted in a 70 percent increase in the use of family planning methods in the intervention location, and a five-fold increase in follow-up visits.

As a result of the original program success, the solution was implemented and adapted in other programs. Overall, more than 900 CHWs and 100 supervisors have been trained on this system. The implementations have supported more than 110,000 clients and more than 400,000 home-based visits. We have seen the following improvements across programs:

  1. Low method discontinuation: Continuous method use rates among clients receiving home-based services ranges from 92 percent to 96 percent across programs.
  1. Increased contraceptive prevalence rate compared to other locations. 
  1. Increase in method uptake: Uptake of method use of 53 percent; these individuals were not using at registration and then started to use a method. 
  1. Increase in method use for first-time mothers: One program (Population Health and Environment) included a specific focus on first-time mothers, a particularly vulnerable population with barriers to family planning and reproductive health services. This program resulted in increased counseling for first-time mothers as well as increased method use for this population (71 percent of first-time mothers using a method).
  1. Increased health worker performance: Health workers using the solution demonstrated a 5-fold increase in the number of client registrations and a 15-fold increase in follow-up visits compared to activity levels before the digital system was introduced. Activity levels have been sustained for more than four years.
  1. Improved quality of facility-based services: Using data on the dashboard from the Citizen Report Card, partners were able to identify areas of low-quality services at health facilities. This evidence provided a basis for dialogue with government health teams, leading to improved client satisfaction and reduced wait times.
  1. Increased transparency about stock: Using information about family planning method stock at the health facility and with the CHW, supervisors and program staff were able to evaluate availability of methods and facility procedures.  
  1. Increased data sharing: Program teams were able to use the data for decisionmaking and streamlined government reporting through program dashboards as well as a partner DHIS-2 integration.

Lessons Learned

  • All programs utilizing FP Plus take a systems perspective, empowering not only the CHW but also the supervisor and program teams. This systems approach helps to increase adoption of the solution, as protocols are in place for continuous follow-up and supervision.
  • The evolution of the FP Plus system across multiple implementations shows the potential to adapt another program to fit the context of the implementation. The program was adapted with improvements based on input from the program team and end-users, using human-centered design activities.
  • An important part of this program is pay-for-performance schemes, which increases motivation and encourages adoption of the program.
  • To support community health worker skills in the programs, we implemented a Mobile Mentor system, which we found to be very important for adoption. This is where a mentor (a highly skilled user) becomes a champion of the program and supports other users in the use of a mobile application.
  • Training supervisors at a facility and empowering them with a mobile application was helpful in improving coordination and communication with the CHWs, in particular, regarding types of methods in stock at the facility.
  • Integration with the Pathfinder DHIS-2 supports data-sharing between systems that streamlined reporting activities and shows the potential of such integrations.
  • The first-time mother focus in the Population Health and Environment implementation demonstrates the unique behaviors of adolescents and the potential for customized interventions for this vulnerable group.

 

Conclusion

Multiple implementations are still active with the FP Plus system in Tanzania, and the programs are continuously monitored for improved family planning counseling and access to family planning and sexual and reproductive health services. Looking toward the future, program teams continue to learn from these implementations and the success of the systems approach, where the program focuses beyond technology to motivation, follow-up, and supervisory structures. Program teams are looking to continue to expand on the Family Planning Plus system and leverage the lessons learned from previous implementations, with the ability to implement in other contexts and with other technology platforms.

References