PROGRESS IN ACTION:
“I believe in the life choice family planning creates,” says Marieme Yade. “Do you?”
Madame Yade is the head of the maternity ward at the health post in Medina Sabakh, a small rural town in Senegal’s peanut-growing region. It is a land of packed red-earth courtyards, whitewashed walls and tin roofs. Madame Yade wears a lab coat over her long skirt, and her hair is tied in a matching headscarf. “With family planning, the women of Medina Sabakh now have a chance to ‘do something’ with their lives,” she says.
At her health post, family planning services are now being integrated with routine child immunizations. Whenever a woman brings a child in to be vaccinated, she is discreetly offered contraceptive counseling and supplies at the same time. This approach neatly sidesteps the obstacles that all too often keep women in Senegal from seeking out contraception: cultural taboos, misinformation and disapproval from men. As a result, contraceptive use is soaring. In the first four months of the project in Medina Sabakh, the number of new family planning users increased by 57%. Now the scenario is being repeated at other health posts across the country, with similar results.
It is one of the many examples of progress underway to bring modern contraception to the women of Senegal. Support comes from the very top: the Minister of Health, Dr. Awa Marie Coll-Seck, is a longstanding champion of family planning.
At the 2012 London Summit on Family Planning, Dr. Coll-Seck announced Senegal’s pledge to raise its contraceptive prevalence rate from 12% to 27% by 2015. Four months later, the government unveiled its National Family Planning Action Plan 2012-2015, a detailed strategy to expand contraceptive access and acceptance. The new plan mobilized a host of resources and commitments throughout the country (see page 88: Decentralization in Action). The early results are good. As of 2013, Senegal’s contraceptive prevalence rate had already jumped four percentage points to 16%.
Part of the increase can be chalked up to the striking improvements being made in the supply chain. The successful Informed Push Model of distribution promises to virtually eliminate stock-outs of contraceptive supplies (see page 88: The Informed Push Model). The Informed Push Model was developed in partnership with IntraHealth, and is now being rolled out nationwide. The government has also doubled its budget for the purchase of contraceptive commodities
and augmented its fleet of delivery trucks.
Efforts are also underway to improve service delivery and expand method mix. Depo-Provera® is very popular in Senegal—it accounts for 40% of the contraceptive use—but access has been difficult. Until now, the injections have been available only from trained health workers in clinics, so women in remote areas have had to travel long distances for care. But a pilot study demonstrated that community workers could administer Depo-Provera® safely, and the Ministry of Health has approved scale-up of the practice to 14 regions.
Senegal is also one of the four countries in the pilot rollout of Sayana® Press, the new single-dose subcutaneous injectable. Sayana® Press combines Depo-Provera® with Uniject™, a special one-use syringe that is completely self-contained. The Ministry of Health has approved the introduction of Sayana® Press at 637 health posts in four regions. But improvements to service delivery and the supply chain will only go so far; the cultural taboos and misinformation surrounding contraception must be confronted as well. The government has begun a multi-phase communications campaign designed to raise awareness of family planning, with targeted messages for women, men, and young people. The media blitz includes television and radio spots, call-in shows, posters, and pamphlets. The government is also recruiting a group of prominent local and national figures to serve as family planning champions, touring the country and acting as public advocates.
Civil society organizations also play a crucial role as advocates. “There is a lot of enthusiasm in Senegal around improving reproductive health,” says Fatou Ndiaye Turpin. She is the program director for Réseau Siggil Jigéen (RSJ), a network of organizations dedicated to empowering women. RSJ recently partnered with IntraHealth to develop an advocacy program for six cities in Senegal, part of a five-year program to improve family planning services in urban areas.
RSJ is also the collaborating partner of Advance Family Planning (AFP), which coordinates a number of advocacy efforts in Senegal. In May 2014, a consortium of advocates led by RSJ and AFP succeeded in winning important new funding commitments from two mayors in Pikine. Following an evidence-based “ask” from the advocacy committee, the mayors each allocated 1 million West African CFA francs (US$2,090) to purchase contraceptive supplies for their district health posts.
Perhaps the most encouraging sign of progress is in the religious quarter. Senegal is a conservative country, with a population that is 94% Muslim. Many people believe that Islam prohibits family planning, a view that some traditional imams share. But in Senegal’s dynamic culture, some imams are stepping up to say that they disagree with this interpretation. The 30-year-old Moussé Fall, for example, is a popular “tele imam” who makes frequent appearances on radio and TV. He is adamant about the acceptability of contraception within Islam. He belongs to the Network of Islam and Population, a group of religious leaders that is working hard to get that
“We organize religious conferences where we explain what Muslims can do in terms of family planning,” says Imam Fall. “Men are accepting family planning more and more because they are getting the right information.”
THE INFORMED PUSH MODEL
In Senegal, as in many poor countries, one reason women do not use contraceptives is because the products are simply not available. Gaps in the supply chain mean that stock-outs are a frequent occurrence at pharmacies and clinics. That spells serious problems for contraceptive users. When a woman is unable to refill her pills or get her next three-month injectable, her contraceptive protection is gone. Supply limitations also mean that many locations offer only one or two types of products—making it difficult for women to find and stick with a method that works for them. A 2011 study in Senegal found that 84% of women had experienced a stock-out of their preferred contraceptive in the past year.
The Informed Push Model of distribution promises to change all that. Instead of relying on pharmacies and clinics to keep track of their inventory and call in orders, the push model employs the same kind of system that is used in the commercial sector for vending machines. A driver with a truckful of supplies visits each point of sale on a regular schedule, topping up the stock and recording quantities of products sold. The data collected by the driver is used to ensure that there is sufficient stock at the warehouse and at each site, and to prime the manufacturers to keep pace with demand. On the systemic level, the information can be used by regional and national decision makers to figure out which contraceptives are most popular and where.
The government of Senegal and IntraHealth pilot-tested the Informed Push Model in Pikine between February and July 2012. Stock-outs of contraceptive pills, injectables, implants and IUDs were completely eliminated at the 14 public health facilities in Pikine over the six months of the pilot project. The government then expanded the model to all 140 public facilities in the Dakar region and six months later the stock-out rates in the region dropped below 2%. Now the Informed Push Model is being rolled out nationwide and is expected to be in place across the country by the end of 2015. Funding for the rapid national rollout is being supplied by the Bill & Melinda Gates Foundation and Merck for Mothers.
DECENTRALIZATION IN ACTION
Decentralization is a watchword in Senegal. It is a guiding philosophy for the government and a driving goal in development. Empowering local actors to set their own agendas—deciding what needs to be done and how—ensures that priorities are aligned with real needs on the ground.
Senegal’s approach to family planning is encapsulated by “the 3 Ds”: democratize, demedicalize and decentralize. This framework was developed by Senegal in the context of the Ouagadougou Partnership and has been adopted by other countries in the region as well. It ensures that family planning interventions are participatory, unencumbered by policy barriers and effectively managed at the regional, district and community levels.
So when Senegal decided to develop a new national family planning strategy, decentralization was built in from the start. It was understood, of course, that high-level policy would be set at the national level, and that the Ministry of Health would assume responsibility for coordination across all the regions of the country. But it was also expected that each region, and each district within each region, would develop its own implementation plan. With the technical assistance of FHI 360, working through the Advancing Partners and Communities Project, that is exactly what happened.
The National Family Planning Action Plan 2012–2015 was launched by the Ministry of Health in November 2012. From December 2012 to April 2013, regions and districts throughout the country held meetings to decide how to implement the policies outlined in the new national plan. Each district established its own goals and benchmarks for expanding contraceptive access, improving service delivery, and raising awareness. A data measurement template was developed so that districts could track and report their progress as they implemented their plans.
In November 2013, the districts and regions began a second round of meetings, this time to evaluate their progress. The data from the measurement templates showed where the plans were succeeding, where they were falling short and where there were gaps. At the regional meetings, district representatives compared notes and talked through resource issues. The whole process became a rolling collaboration, with everyone sharing ideas and lessons learned.
In the Saint-Louis region, for example, representatives from the Pété district described their great success with TutoratPlus, an on-the-job training program for health care providers. TutoratPlus is offered through IntraHealth with funding by USAID, and is designed to improve provider skills on a range of contraceptive methods. One of the nurses in Pété who received the IUD training went from performing only three IUD insertions per year to performing 12 per month. When the other districts in Saint-Louis learned of this, they decided they should implement the program as well. The result: IUD insertion rates are now up throughout the region.
The district and regional meetings also led to much-needed funding realignments. The Kédougou region, for example, initially had few development partners and very little funding for reproductive health. But the region came up with a compelling, detailed implementation plan for the new family planning initiative, showing clearly what activities were needed. That enabled the Ministry of Health to work with partners such as WHO, Agence Française de Développement (AFD) and the Muskoka Initiative to redirect funds toward Kédougou’s new goals.
51. Daff BM, Seck C, Belkhayat H, Sutton P. Informed push distribution of contraceptives in Senegal reduces stock-outs and improves quality of family planning services. Glob Health Sci Pract. 2014;2(2):245-252. http://dx.doi.org/10.9745/GHSP-D-13-00171