Village Health Committees drive Family Planning Uptake

1. Village Health Committees drive Family Planning Uptake

2. Session Outline Background Village Health Committees Program highlights Working with religious leaders Expanding access to IUD services Lessons learned & conclusions

3. Background: Guinea Total population:10.1 million (70 % rural) Religion: 85% Muslim; 8.7% Christian MMR: 980 deaths/ 100,000 live births U5MR: 163/ 1000 live births TFR: 5.7 births /woman CPR: 6% (modern) Unmet need for FP: 21% (Spacing 13% - limiting 8%) Knowledge: any FP method: 92% -- IUD: 12.4% Use of the IUD: 0.1%

4. Program area: Mandiana and Kourroussa districts - Upper Guinea source for population data, 1996 Census 86 km to capital of Upper Guinea (Kankan) Travel difficult between June - November due to rains No telephone in Mandiana, communication by radio Upper Guinea is a Savannah zone in the northeast corner of the country, bordering Mali and Cote d’Ivoire. The region is sparsely populated with a density of 9.1 inhabitants per square km, less than half the national average Kankan is the capital and the region is divided into 8 prefectures. Mandiana Prefecture, with a population of 170,881, is divided into 12 subprefectures. Mandiana is one of the more inaccessible areas of Guinea. Travel between the capital and Mandiana is very difficult during the rainy season, from June to November. source for population data, 1996 Census 86 km to capital of Upper Guinea (Kankan) Travel difficult between June - November due to rains No telephone in Mandiana, communication by radio Upper Guinea is a Savannah zone in the northeast corner of the country, bordering Mali and Cote d’Ivoire. The region is sparsely populated with a density of 9.1 inhabitants per square km, less than half the national average Kankan is the capital and the region is divided into 8 prefectures. Mandiana Prefecture, with a population of 170,881, is divided into 12 subprefectures. Mandiana is one of the more inaccessible areas of Guinea. Travel between the capital and Mandiana is very difficult during the rainy season, from June to November.

5. Health System in Mandiana and Kouroussa Districts Each district is served by: one district hospital, 10-12 health centers and 15 - 20 health posts Villages are located up to 45 kilometers from the nearest health facility

6. What were the gaps in FP? Perceived religious opposition to FP Men: FP averse to discussing FP – “women’s business” Limited awareness and acceptance of longer acting methods Limited access to a wide range of FP options – particularly LAPMs (IUD..) IUD services only available in urban facilities in Mandiana

7. Program activities & timeline Advocacy with Imams has resulted in a change in attitudes with 1/3 thinking FP is acceptable in 2002 as compared to 1/5 at baseline in 1999. (JHUCCP)Advocacy with Imams has resulted in a change in attitudes with 1/3 thinking FP is acceptable in 2002 as compared to 1/5 at baseline in 1999. (JHUCCP)

8. Village Health Committees

9. Village Health Committees: Composition 7 – 9 members including: 1 President, 1 Vice President and 1 Treasurer,) 1 TBA 1 nutritionist 2 FP agents (1 male – 1 female) 1 Traditional healer 1 Hygienist Local leaders (chiefs, imams, villages elders) 133 VHC established in Mandiana district – 73 (55%) have received official government legal recognition (CS14 final evaluation)

10. VHCs: Roles and responsibilities Vital registration Sensitization and community education Mobilizing funds for the MURIGAs (community-funded emergency loan funds) Organizing community meeting for feedback on vital events and MURIGAS Organizing sessions per intervention: Nutrition, MNCH, FP, HIV/AIDS, Immunization, Malaria and hygiene and sanitation Monthly meetings – updates and work planning Serve as interphase between community and health facilityies Support facility based providers in outreach and health days Support community agents: resupplies- reports

11. Murigas facilitate financial access to FP services

12. Village Health Committees: Roles and responsibilities CBD agents 1 man and 1 woman / VHC – total 450 Basic 5 day training + refresher training Health education (group and individuals) Follow up FP users Referrals (injectables and longer acting methods) Advocacy religious leaders Data collection and reporting Collaboration with health facilities

13. Community Based Information system Use of information easily understood by community members: Births, deaths, maternal and child deaths, immunization of children and pregnant women, number of contraceptives sold, FP users, etc Development of data collection tools and routine data collection Monthly reporting cards Selection and training of VHC members responsible for data collection Collaboration with health centers & posts Monthly meetings for data sharing and feedback Participation in district supervisory visits (semester)

14. Addressing Religious barriers

15. Addressing Religious barriers Predominance of Muslim religion Religious leaders: Highly respected at the community level Important sources of information in rural areas Very influential in decisions about use of FP Religious resistance to use of FP: 30% opposed to use of contraception – 12.5% cite religion as reason for not using FP (DHS 2005) Koran is supportive of birth spacing – however erroneous interpreted Limited knowledge among religious leaders about modern family planning . .

16. Specific activities with religious leaders 3 day workshops – targeting 225 village Imams Basic FP information Clarify relationship between Islam, FP and RH as per the Koran Role of community leaders in promoting FP Men’s responsibility vis a vis their families Action planning to introduce FP information during sermons, community meetings, ceremonies.. Recommendations for the expansion of FP services in the district

17. Coranic references support birth spacing Mothers who wish to completely breastfeed wlll breastfeed for 2 full years (Sourate 2, verse 233) …and her pregnancy and weaning will last 30 months (sourate 46 verse 15) They (the mother and child) must be maintained and dressed appropriately by the father of the child: No soul will need to carry a burden that he is unable to sustain. The mother will not suffer as a result of her child – nor the father as a result of his child (Sourate 2, verse 233) ;

18. Testimonials from Imams Testimony from Sekou DIALLO, Imam from Komola - Kouroussa «  Me, I do not see any contradiction between what is said in the Koran and what the trainers from SC are saying. All works for the well being of mother and the child. In this sense, I support family planning » All the Imams « The Koran mentions that all children should be breastfed for 24 months. »

19. Expanding access to IUD services

20. Expanding access to IUD services in Mandiana District 6 month pilot program 2004 – 2005 (FHI) Goal: Expand access to comprehensive IUD services by: Increasing community and individual awareness of and interest in using long-term contraceptive methods; Training health providers in IUD insertion and removal (2 rural health centers PLUS the urban health center and Mandiana Hospital) Training staff in satellite health centers to promote the use of IUDs (referrals)

21. Health system strengthening: Trained agents to provide select FP services and referrals Trained/equipped 4 health facilities to provide IUD services (staff training, IUD insertion equipment, BCC materials) Established referral linkages between communities and satellite health centers Established a district supervisory team Integrated IUD data into district and community HMIS Authorization to allow midwives to insert IUDs (policy) Key strategies and activities IUD services revitalized in 2 urban health facilities Mandiana Hospital & urban health center 2 additional health centers equipped to provide IUD services: 2 Rural health centers located 40 and 75 km from Mandiana Hospital 9 health providers in these health units trained in IUD insertion and removal (Engenderhealth) 22 Providers in 9 health centers trained to counsel, refer and follow-up clients post insertion Authorization from MOH to allow midwives to insert IUDs !! (Policy ) Total of 113 villages reached with IUD services IUD services revitalized in 2 urban health facilities Mandiana Hospital & urban health center 2 additional health centers equipped to provide IUD services: 2 Rural health centers located 40 and 75 km from Mandiana Hospital 9 health providers in these health units trained in IUD insertion and removal (Engenderhealth) 22 Providers in 9 health centers trained to counsel, refer and follow-up clients post insertion Authorization from MOH to allow midwives to insert IUDs !! (Policy ) Total of 113 villages reached with IUD services

22. Key strategies and activities (2) BCC/IEC activities around service delivery points VHC theatre and songs Individual counseling by CBD agents and health providers Weekly sensitization sessions by community agents Radio broadcasts and debates Developed IEC/BCC materials

23. Testimonials (2) “We are enchanted and satisfied with this long-acting contraception method because of its advantages and cost which is 1000 Gf.(22 cents) ……However, for those of us who live 25km or more from a SDP, we are forced to pay at least 10000Gf, for transport to reach the SDP. Which means the IUD will cost us 11000 Gf. ……. One can sensitize our people, but one cannot cover the expenses of the services for them, that needs to come out of each one’s pocket” Imam of a village located at 25 km from a SDP, Kantoumanina

24. Results: Increase in IUD uptake 73 IUDs inserted over a period of 6 months compared to only 13th before the intervention 73 IUDs inserted over a period of 6 months compared to only 13th before the intervention

25. Higher IUD utilization in intervention district 73 IUDs inserted over a period of 6 months compared to only 13th before the intervention 73 IUDs inserted over a period of 6 months compared to only 13th before the intervention

26. Trends in contraceptive use

27. Lessons learned Community participation is key in improving use of health services Village Health Committees proved an essential player in increasing their villages’ sense of having a stake in health services

28. Lessons learned & conclusions Targeted advocacy with religious leaders was beneficial in making FP acceptable to women and men Discussing birth spacing/FP in the context of Islam helped generate support for the use of FP Religious leaders (Imams) played a pivotal role by providing a gateway to the community clarifying misconceptions about the Koran Helping to educate communities about the importance of birth spacing /FP Reaching men – support the use of FP

29. Replication of the VHC ADRA – Siguiri PRISM phase II (Kankan) PLAN – 5 districts Guinee Forestiere

30. Acknowledgements SC team in Guinea Local partners: NGOs, MOH Community members Flexfund – FHI –- PLAN - ESD