Evolution of a large-scale community-based contraceptive distribution program in Kinshasa, DRC based on process evaluation

Julie H. Hernandez, Pierre Z. Akilimali, Mbadu Fidèle Muanda, Annie L. Glover, Jane T. Bertrand

Research output: Contribution to journalArticlepeer-review

Abstract

Midterm process evaluation results indicated that design and implementation failures hindered the program’s success, notably: (1) the short-acting methods provided by community-based distributors (CBDs) offered limited choice; (2) the nominal revenue retained from selling the methods provided limited motivation for the volunteer CBDs; and (3) the model was poorly coordinated with the existing clinical service system, partly because of challenging systems issues. In the revised model, the CBDs will also provide subcutaneous injectables and emergency contraceptive pills, retain more revenue from contraceptive sales, and have better interaction with the existing system including conducting monthly mini-campaigns to increase visibility and attract more clients. 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.

Original languageEnglish
Pages (from-to)657-667
Number of pages11
JournalGlobal Health Science and Practice
Volume6
Issue number4
DOIs
StatePublished - Dec 2018

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