Reproductive Health and Family Planning in Kenya The Pathfinder International Experience

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Reproductive Health ad Family Plaig i Keya The Pathfider Iteratioal Experiece October 2008 Stephe Ndegwa, Commuicatios Officer Pathfider Iteratioal/ Keya Pamela Oduso Istitutioal Capacity Buildig

1 Reproductive Health ad Family Plaig i Keya The Pathfider Iteratioal Experiece October 2008 Stephe Ndegwa, Commuicatios Officer Pathfider Iteratioal/ Keya Pamela Oduso Istitutioal Capacity Buildig Coordiator, Pathfider Iteratioal/ Keya Lida Casey Coutry Represetative, Pathfider Iteratioal/ Keya Keya was oe of the first Africa coutries to recogize the importace of Family Plaig (FP) as a core elemet i ecoomic ad social developmet. As early as 1957, the Pathfider Fud assisted the Family Plaig Committees of Mombasa ad Nairobi to ope FP cliics, which wet o to become the Family Plaig Associatio of Keya i 1962 (ow Family Health Optios Keya), affiliated with the Iteratioal Plaed Parethood Federatio. Facig a aual populatio growth rate of 3 percet, the Govermet of Keya (GoK) icorporated FP ito the coutry s overall developmet policy i 1965, ad by the mid- 1980s, the growth rate bega to declie.1 Keya s Total Fertility Rate (TFR) declied from eight childre per woma i the late 1970s, to 4.7 childre by the ed of the 1990s. But these dramatic declies i fertility rates have ow stagated, ad eve reversed i some istaces.2 The 2003 Keya Demographic ad Health Survey (KDHS) foud a TFR of 4.9 childre per woma. Correspodigly, the Cotraceptive Prevalece Rate (CPR), which had grow by six percet i the early 1990s, has also stagated at 39 percet amog married wome betwee 1998 ad Cotraceptive discotiuatio rates icreased from 33 percet of users i 1998 to 38 percet i 2003, liked to problems i cotraceptive supply ad weakesses i quality of care ad cotiued high levels of poverty.4 A 2003 study showed that umet eed for FP i Keya has remaied high, with 20 percet of births uwated ad 25 percet mistimed. Today, oly 50 percet of the total potetial demad for FP is beig satisfied by use of moder methods Keya Demographic ad Health Survey 2003, July 2004 Ibid Ibid Ibid Treds ad Determiats of Umet Need for Family Plaig i Keya, DHS Workig Papers, 2008 No. 56, USAID. photo: APHIA II NC

2 For more tha 50 years, Pathfider Iteratioal has built successful approaches to deliverig quality Reproductive Health ad Family Plaig (RH/FP) services aroud the world. Preset i Keya sice 1969, ad with a coutry office sice 1974, Pathfider has provided traiig, techical assistace, ad support to a vast array of govermet ad ogovermet parters i the provisio of quality RH/FP care ad HIV/AIDS prevetio, treatmet, care, ad support. At the same time, global HIV fudig has icreased eormously, while FP fuds have either shruk or remaied at the same level. I 2004 the Resource Flows Project tracked FP ad HIV/AIDS fudig by govermet, doors, foudatios, ad multilateral orgaizatios. 6 Results of the survey show that iteratioal fudig for FP activities had remaied static amidst growig populatios ad greater eed. While HIV/AIDS programs received just 9 percet of developmet assistace populatio fuds i 1995, they received 43 percet i Coversely, FP programs, which accouted for 55 percet of populatio fuds a decade ago, received oly 23 percet of those resources at the time of the report, ad subsequet reports cofirm this cotiuig tred. Cosiderig the importat role that FP iformatio ad services ca play i prevetig, detectig, ad treatig Sexually Trasmitted Ifectios (STIs), icludig HIV, cotiued efforts to stregthe FP programs are icreasigly vital. Buildig o past successes For more tha 50 years, Pathfider Iteratioal has built successful approaches to deliverig quality Reproductive Health ad Family Plaig (RH/FP) services aroud the world. Preset i Keya sice 1969, ad with a coutry office sice 1974, Pathfider has provided traiig, techical assistace, ad support to a vast array of govermet ad ogovermet parters i the provisio of quality RH/FP care ad HIV/AIDS prevetio, treatmet, care, ad support. Pathfider stregthes the istitutioal ad techical capacity of parter orgaizatios by providig resources ad techical assistace to develop their fiacial sustaiability ad techical expertise. I 1985, Pathfider developed a comprehesive Commuity-Based Distributio (CBD) strategy for the GoK that icluded the establishmet of District Populatio Officers to work with commuities, which was subsequetly adopted as the atioal program. 7 Uder the Family Plaig Service Project (FPSP) i the 1990s, parters raged from church etworks ad uiversities to public sector agecies, atioal NGO etworks, ad private practitioers. Iovative approaches employed uder FPSP have icluded commuity-based, workplace, ad marketplace service delivery iitiatives. Pathfider has also developed ad refied iovative programs i the delivery of postabortio care, youth-friedly services, ad peer educatio programs i Keya. I the 1990s, as HIV ad AIDS bega to surface as a urget public health issue, existig parters ad services were ehaced to itegrate HIV with FP programmig. By the year 2000, Pathfider was rollig out the first large-scale Commuity ad Home-Based Care (CBHC) program for people livig with HIV i Keya, spaig five provices ad fifty local implemetig parters. By buildig o a foudatio of former CBD agets ad maitaiig FP withi the mix of CHBC services, Pathfider has built a model for itegratig ad stregtheig services at the commuity level. Curret programs address HIV ad RH/FP i a itegrated fashio, focusig o buildig a cotiuum of prevetio, treatmet, care, ad support from commuity to facility levels. While the fudig shift to HIV creates challeges, it also creates opportuities for efficiet use of other resources. Pathfider builds o its implemetig parters commuity ad cliic programs to refocus o RH/FP. 6 UNFPA/UNAIDS/NIDI Resource Flows website ( 7 Courageous Pioeers, Pathfider Iteratioal, Reproductive Health ad Family Plaig i Keya Pathfider Iteratioal

The diversity of Pathfider s experiece ad approaches to RH/FP programmig is demostrated i a few examples of successful itervetios: Commuity-Based Distributio (CBD) of FP Methods: Begiig i 1980,

3 The diversity of Pathfider s experiece ad approaches to RH/FP programmig is demostrated i a few examples of successful itervetios: Commuity-Based Distributio (CBD) of FP Methods: Begiig i 1980, Pathfider helped umerous parters, icludig Maedeleo ya Waawake Orgaizatio (MYWO), the Family Plaig Associatio of Keya (FPAK), Nairobi City Coucil, Aglica Church of Keya (ACK), ad the MOH to iitiate ad roll out the first large-scale CBD efforts i the coutry. Leadig this effort ad buildig o its grassroots etwork, MYWO emphasized IEC ad built the largest CBD etwork i the coutry. I 1991, Pathfider also worked closely with the govermet to develop the first atioal CBD traiig curriculum. Betwee 1993 ad 2000 aloe, CHWs affiliated with MYWO served more tha 710,000 ew FP users ad reached more tha 10 millio people through IEC activities. Uder MYWO, ew iitiatives icluded fee-for-service care ad distributio of pills ad ijectables through depot holders. Pathfider supported the developmet of a strategic pla that was crucial to restructurig the project for sustaiability. A revolvig fud for CBDs to develop icome-geeratig activities was also itroduced, while traiig i fiacial maagemet ad strategic plaig was provided for project maagemet ad key board members The Mkomai Cliic Society (MCS) was fouded i 1980 to make basic health services accessible to low-icome families livig i urba slums of Mombasa. Beyod basic curative services, MCS provides ateatal care, child welfare, ad FP services. At the commuity level, MCS trais CHWs to establish cotact with wome ad me with limited access to FP, ad this etwork of coverage has made MCS the leadig source of FP services amog Mombasa NGOs. Begiig i 1992 with USAID fudig, ad from 2003 to 2004 with private support, Pathfider supported MCS by traiig physicias, urses, midwives, CHWs ad supervisors i the itegratio of FP/RH with STI/HIV/AIDS programs, cotraceptive techology, ad maagemet of emergecy cotraceptio. With FPSP support betwee 1994 ad 1999, the MCS project reached 591,129 people through group meetigs ad home visits, recruitig 69,782 ew FP users, ad servig 217,109 FP revisit cliets. Pathfider provided techical assistace i fiacial ad program maagemet, as well as essetial equipmet ad supplies to eable the cliic ad its programs to expad sustaiably. MCS remais a Pathfider istitutioal capacity-buildig best practice ad atioal model for provisio of sustaiable facility-liked CBD of RH/FP services. Mothers take time out from a workshop i order to feed their childre. Easy access to RH/FP services eables wome to cotiue with productive activities after birth. photo: Stephe Ndegwa Pathfider Iteratioal Reproductive Health ad Family Plaig i Keya 3

4 Adolescet Sexual ad Reproductive Health ad Postabortio Care: I additio to providig mucheeded services at this busy atioal referral hospital, the HRC successfully advocated for the acceptace ad wider provisio of PAC services, evetually cotributig to policy chages at the atioal level. Begiig i 1990, with fudig from USAID, Pathfider assisted Keyatta Natioal Hospital (KNH) to establish ad maage a adolescet High Risk Cliic (HRC) i collaboratio with the Departmet of Obstetrics ad Gyecology of the Uiversity of Nairobi. The HRC focused o expadig Postabortio Care (PAC) to iclude quality couselig, FP, ad referrals for STIs ad HIV/AIDS. The cliic cotiues to provide RH ad cotraceptive iformatio, couselig, ad services to youg wome ad me, while educatig their parters ad spouses o the hazards of uprotected sex ad usafe abortio. I additio to providig much-eeded services at this busy atioal referral hospital, the HRC successfully advocated for the acceptace ad wider provisio of PAC services, evetually cotributig to policy chages at the atioal level. Now called the Adolescet Couselig/ Youth Cliic, it has expaded services to iclude Volutary Couselig ad Testig (VCT), ad today the cliic is ru idepedetly by KNH. The model has bee adopted by other hospitals i the coutry ad replicated by several NGOs. Sigificatly, the HRC ispired the establishmet of the Nairobi Wome s Hospital i 2001, which today serves as a cetre of excellece i providig RH/FP ad pioeerig geder-based violece services. Urba Reproductive Health Iitiative (URHI II) Supported by USAID s Regioal Ecoomic Developmet Support Office (REDSO/ESA) ad i partership with the SEATS project, Pathfider maaged the secod phase of URHI ( ), which sought to improve the quality of RH/FP services i urba settigs. The iitiative provided high-risk urba groups, such as youth, me, sex workers, ad slum dwellers, with iformatio o codoms, dual method use, ad HIV/STI prevetio. The first phase of the iitiative focused o improvig ifrastructure ad quality of care i facilities servig the hard-to-reach, while the secod phase focused more o urba CBD services. Codom distributio the mai service delivery compoet used a multiproged approach comprisig CBD agets, peer motivators, referral sites, ad codom dispesers. More tha three ad a half millio codoms were distributed over a 12-moth period. Secodly, Iformatio, Educatio ad Commuicatio (IEC) materials were developed ad distributed through youth ceters, youth ad wome s clubs, schools, ad commuity meetigs. The project also supported commuity iitiatives i maagig healthcare at the grassroots level, effectively formig a lik betwee beeficiaries ad implemeters. The URHI provided valuable lessos i the developmet of participatory commuity approaches i the urba settig, as well as best practices for mobile services, reachig youth ad coalitio buildig to solve local commuity problems. Itegrated Reproductive Health ad Peer Couselig i Keya Uiversities Begiig i 1988 with USAID fudig, ad later with private support, Pathfider supported RH ad peer couselig at Keyatta Uiversity (KU) i Nairobi ad later 4 Reproductive Health ad Family Plaig i Keya Pathfider Iteratioal

(1990-2004) at Egerto Uiversity i Njoro ad, sice 2006, at Jomo Keyatta Uiversity of Agriculture ad Techology.

5 ( ) at Egerto Uiversity i Njoro ad, sice 2006, at Jomo Keyatta Uiversity of Agriculture ad Techology. To reduce the prevalece of STIs ad HIV, as well as uiteded pregacies, studets receive RH/FP guidace ad couselig through peer-based IEC activities. Off-campus activities also target i- ad out-of-school youth. With icreased awareess ad use of cotraceptives, the rate of uwated pregacies at KU campuses dropped by 50 percet betwee 1992 ad 1998, ad the umber of studets seekig treatmet for STIs declied by 22 percet at KU ad by 50 percet at Egerto. This program has stregtheed the uiversities capacities to respod to their studets chagig RH/FP eeds. Pathfider is curretly ecouragig the KU admiistratio to fully fud maistreamig the peer educator program, icludig staff time. The Uiversities of Dar i Tazaia (1997) ad Makerere i Ugada (2007) iitiated similar programs based o close observatio of the Keya projects. Recogizig that these programs cotribute to developig leadership skills, the program curretly provides short career iterships that place peer educators with APHIC II NC parters, where they gai hads-o experiece i commuity outreach. Commuity-Based HIV/AIDS Prevetio, Care ad Support Project (COPHIA) Fuded by USAID ( ) ad leveraged by UNDP ( ), the COPHIA project built the capacity of 50 local parters ad commuities i five provices to provide comprehesive home-based care ad support to People Livig With HIV (PLWH), their caregivers, ad families. I additio to traiig caregivers i the provisio of HBC services ad likig cliets to a wide rage of health services, psychosocial support, legal protectio, ad icomegeeratig activities, the COPHIA CHWs distributed codoms ad raised awareess about RH/ FP, addressig HIV prevetio ad tacklig stigma ad discrimiatio agaist PLWH. May COPHIA CHWs were former CBD agets who cotiued to provide FP methods directly. Nurses from referral health facilities served as cliical supervisors of CHWs ad esured close commuity-facility likages for FP ad other health services. These CHWs were traied by the COPHIA project to support their eighbors i Nairobi s Mukuru slum who are livig with HIV. Photo: Mary K. Burket Commuity-Based Family Plaig i Keya Project I July 2003, with fudig from a private source, Pathfider udertook a three-year project to reivigorate FP services i selected districts of Wester Keya ad Mombasa. By icreasig access to FP services ad iformatio through CBD ad strog likages to cliical services, the project sought to reduce uwated pregacies. By buildig o past efforts that stregtheed the techical ad maagemet capacity of three NGO parters, Pathfider revived FP as a priority withi these orgaizatios ad their catchmet areas. The project built o COPHIA parterships as well as Pathfider s Prevetio of Mother to Child Trasmissio Project i oe of the three areas, to esure strog likages betwee the FP activities, CBHC ad PMTCT. Pathfider was pleased to discover that the three parter agecies had cotiued their CBD despite cessatio of fiacial support evidece that capacity buildig efforts uder previous projects had had a positive impact. Pathfider Iteratioal Reproductive Health ad Family Plaig i Keya 5

Curret FP-related Iitiatives The AIDS, Populatio, ad Health Itegrated Assistace Projects APHIA II (Nairobi, Cetral ad North Easter Provices) Uder the itegrated APHIA II projects, Pathfider curretly

6 Curret FP-related Iitiatives The AIDS, Populatio, ad Health Itegrated Assistace Projects APHIA II (Nairobi, Cetral ad North Easter Provices) Uder the itegrated APHIA II projects, Pathfider curretly supports 23 health facilities with FP services i Nairobi, ad 138 i Cetral Provice, with more plaed for North Easter Provice. These sites rage from stad-aloe VCT services to dispesaries, health ceters, ad hospitals offerig a broad health package of HIV prevetio ad comprehesive HIV ad TB treatmet ad care. A group of mothers liste to a discussio about PMTCT at the Mathare North Health Ceter. Sice their iitiatio i 2006 ad 2007, the APHIA II projects have traied health care workers i cotraceptive techology updates, itegratig FP ito VCT ad ito PMTCT, i log-actig ad permaet methods, PAC, youth-friedly services, ad cervical cacer screeig. Special focus has bee give to improvig the quality of couselig ad FP service provisio, providig essetial equipmet ad itegratig FP ito HIV services, ad o traiig. Commuity-based activities support CBD ad codom distributio, as well as prevetio amog those who are HIV-positive. Youth-focused activities address HIV prevetio ad RH educatio ad likages to services. Photo: Mary K. Burket Prevetio of Mother-to-Child Trasmissio (PMTCT) services I 2002, with fudig from the Ceters for Disease Cotrol, Pathfider lauched its PMTCT project i Keya, drawig o its established expertise i itegratig HIV/AIDS ad RH/FP services. The program has sigificatly expaded coverage ad quality of PMTCT services i the coutry, coverig 14 districts i Nairobi, Cetral, ad Easter Provices. Pathfider has cosistetly provided leadership i PMTCT programs i Keya, with almost uiversal public sector facility coverage i program districts. I Keya, almost 50 percet of all pregacies are either uwated or uplaed. Because HIV prevalece amog wome of reproductive age stads at 9.2 percet, 8 esurig access to ad use of effective RH/FP methods does ot oly prevet uplaed pregacies, but is also a core part of the coutry s HIV prevetio strategy. Cosequetly, Pathfider stregthes FP services withi the PMTCT cotext, providig i-service traiig ad o the job support to service providers i the use of FP methods for both HIV-positive ad HIV-egative wome. Refocusig o FP Keya faces several serious gaps i assistig wome to achieve the desired timig ad umber of pregacies. While strog FP programs ca sigificatly cotribute to the prevetio, detectio, ad treatmet of STIs, icludig HIV, FP requires ew attetio, both as a stad aloe program ad as part of ogoig itegrated programs. 8 Keya AIDS Idicator Survey 2007 (Prelimiary Report) 6 Reproductive Health ad Family Plaig i Keya Pathfider Iteratioal

The causes of recet reverses i fertility treds eed to be better uderstood to make FP programs more effective, ad the high level of umet eed for FP demads cosistet efforts to make quality services

7 The causes of recet reverses i fertility treds eed to be better uderstood to make FP programs more effective, ad the high level of umet eed for FP demads cosistet efforts to make quality services more accessible. The curret high levels of fudig for HIV/AIDS must also be applied/refocused to improve overall service quality, icludig RH/FP services. By itself, however, this strategy will ot fully address the prevailig limitatios. Pathfider is adoptig several approaches to revive FP activities i Keya: Policy I recet years, the GoK has show a icreased commitmet to allocatig resources for RH to the MOH s Departmet of Reproductive Health, ad i 2007, a more comprehesive atioal RH policy was lauched. However, these resources are iadequate to meet the curret demad for comprehesive RH/FP services i the coutry. Pathfider ad like-mided NGOs ca combie efforts to lobby health authorities ad parliametarias to icrease RH/FP fudig. A otable iitiative towards meetig this goal is the Natioal Coordiatig Agecy for Populatio ad Developmet, which is workig with key parters, particularly the Parliametarias Network o Repositioig FP as a atioal priority. This etwork icludes a umber of Members of Parliamet who are RH advocates ad former beeficiaries ad parters of Pathfider s RH/FP programs. Supply of cotraceptives Fudig for FP i geeral has bee a challege sice the advet of the HIV/AIDS epidemic. Combied with challeges i efficiet logistics maagemet, public sector facilities still experiece occasioal stock-outs of specific cotraceptives, with egative impacts o method choice ad discotiuatio rates. Log-actig methods, such as IUDs ad Norplat, ad permaet methods (volutary surgical cotraceptio for me ad wome) must be cosistetly available, ad service providers must have the skills to deliver these methods. While these challeges exceed the ability of idividual NGOs to ifluece them, etworkig ad advocacy led by the MOH i collaboratio with NGOs could help to move the dialogue forward. Family plaig ad reproductive health is a importat part of CHW traiigs. This traier is explaiig the mestrual cycle durig oe of APHIA II NC s CHW traiigs i Cetral Provice. Photo: Mary K. Burket Traiig FP techology is cotiuously chagig. Ufortuately, the majority of cliical staff i the coutry s health sector are ofte uaware of ew developmets ad caot offer a full rage of services to cliets. I additio, there is a high turover of MOH staff as health care workers move out of public service to other sectors or coutries, or take exteded breaks for further study. Still, regular traiigs are critical for existig cliical staff. Male ivolvemet The full ivolvemet ad participatio of me i FP has largely bee lackig. Me still view FP solely as a woma s resposibility. Cosequetly, they eed to be iformed ad educated o their roles i effective FP, ad the optios available to them. Approaches should have a heavy commuity- ad worksite-focus to reach me where they ca most easily access iformatio ad services. Small chages to service delivery ca be explored i order to make health facilities more male- ad couple-friedly. Pathfider Iteratioal Reproductive Health ad Family Plaig i Keya 7

A woma ad her child stad ext to the recetly reovated MCH/FP cliic at the Embu Provicial Geeral Hospital i Easter Provice. The reovatios were fuded by USAID through the COPHIA II project.

8 A woma ad her child stad ext to the recetly reovated MCH/FP cliic at the Embu Provicial Geeral Hospital i Easter Provice. The reovatios were fuded by USAID through the COPHIA II project. photo: Stephe Ndegwa Focus o youth ad adolescets Accordig to a joit report by the MOH, Keya Medical Associatio, Federatio of Wome Lawyers i Keya, ad IPAS, 16 percet of all reported abortio cases i Keya ivolve girls aged years of age. The 2003 study reveals that 300,000 abortios are performed i the coutry each year which traslates to about 800 abortios ad seve related deaths daily. PAC itervetios are urgetly eeded for this most at-risk segmet of the populatio. Through its APHIA II projects, Pathfider is scalig up traiig ad techical assistace focused o PAC, icludig youth-friedly PAC. Itegratio of HIV/FP With sigificat fudig curretly available for HIV ad AIDS programmig, may opportuities exist to reitroduce FP through chaels i the service delivery etwork. Existig HIV/AIDS prevetio, treatmet, care, ad support structures offer veues, services, ad staff that ca be stregtheed to build FP ito each service delivery poit. Activities that stregthe physical ifrastructure, supervisio, quality of care ad availability of huma resources, ca all beefit RH/FP services whe properly itegrated. Coclusio Although Keya has bee log held as oe of Africa s FP successes, both i the use of cotraceptives ad other RH services, there is still substatial umet eed. With the Govermet s stated commitmet to free health services for poor Keyas yet to bear full fruit, meetig this eed demads sigificat NGO ad private sector ivolvemet. Moreover, the demad for HIV/AIDS iformatio ad services calls for maximizig resources ad expertise by itegratig efforts at both commuity ad cliic level. Ultimately, Pathfider s decades of experiece i supportig successful RH/ FP services icludig the curret itegratio uder the APHIA II programs will cotribute to stregtheig RH/FP services agai i Keya. Pathfider has prove that deep commuity ivolvemet, leadig to local leadership, owership, ad directio ca make for permaet progress. Pathfider Iteratioal/Headquarters 9 Gale Street, Suite 217 Watertow, MA USA Tel: Pathfider Iteratioal/Keya Iteratioal House-Mezzaie floor Mama Ngia Street P.O.Box , Nairobi, Keya Phoe: (020) / / / Cell: / Reproductive Health ad Family Plaig i Keya Pathfider Iteratioal 0908/700

The MISP is not just kits of equipment and supplies; it is a set of activities that must be implemented

The MISP is not just kits of equipment and supplies; it is a set of activities that must be implemented Miimum Iitial Service Package 11 This Chapter describes a series of actios eeded to respod to the reproductive health (RH) eeds of populatios i the early phase of a refugee situatio (which may or may ot