TCI University Toolkit: Demand Generation
COVID-19 and Family Planning/Reproductive Health
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Community Health Workers
What Is It?
Volunteers or paid employees that bring health information and services to people where they live and work, rather than requiring clients to visit a facility. Community health workers (CHWs) are an important cadre of workers in a health system. Personal contact with such a well-informed community member can help alleviate women’s and men’s fears about family planning, present contraceptive method options for spacing or limiting births, and facilitate access to family planning and other related services, such as maternal, neonatal and child health services, in both the government and private sector.
Using CHWs is a globally recognized effective approach to increasing uptake of family planning. When trained and provided with the necessary tools and resources, CHWs can help fill gaps in both demand generation and service delivery.* These community-based activities can take place at the home, at work, or other spaces where people gather, such as marketplaces, mosques or churches, and community meetings and celebrations.
*Most CHWs are allowed to provide non-clinical contraceptive methods – condoms, pills, fertility awareness methods.Many countries also allow CHWs to give injectable contraceptives, and some are even moving toward allowing them to give implants.You should check with your country’s family planning service delivery guidelines to see who is allowed to provide different methods.
What Are the Benefits?
- CHWs are trusted community members with the knowledge and understanding of their communities’ unmet needs for health and family planning.
- They are often recognized and mandated by the Ministry of Health to provide health services.
- CHWs can contribute to reduced waiting times at facilities if a woman can get her preferred method from a CHW (usually pills or condoms, and sometimes injectables or implants).
- Task sharing selected family planning interventions to CHWs, such as counseling, can relieve the workload of higher-level providers, allowing them to focus on quality provision of provider-dependent methods such as the intrauterine device (IUD) or sterilization.
- When linked to health facilities, CHWs can refer clients for contraceptive methods that they themselves cannot provide.
- CHWs can provide follow-up care, for example, home visits after delivery.
How to Implement?
The decision to use CHWs and a community outreach strategy should not be taken lightly. While extremely effective, it is a major undertaking that takes careful planning, initial and refresher trainings to keep CHWs’ knowledge and skills up to date, ongoing supervision that is supportive and effective, and continuous monitoring for adjustments.
The following are general guidelines for TCI geographies to follow, but understand that there are many models for using CHWs in family planning that have been found to be successful.
Identify Existing CHWs Who Can Provide Family Planning Information and Services
Working with existing CHWs also relieves the burden of recruiting and selecting new CHWs, which can take considerable time and thought. New CHWs may also need approval by the government, another time-intensive process.
Finally, CHWs are likely already linked to a health facility, a national or regional health worker program, or an NGO. You can partner with these institutions to enhance your program as well as draw upon their resources and technical expertise.
Assess the CHWs’ Level of Education, Capacities and Resources
- What is the highest level of education they have attained? Are they literate?
- What training have they received?
- Who is supervising them? To whom do they report?
- Who else is on their health team (if there is one)?
- What tasks are they already expected to carry out?
- Are they expected to keep records and follow up with clients/community members?
- Are they paid or unpaid/volunteers?
- If volunteers, what motivates them to do their work?
- Do they have resources to travel? From whom do they get the resources?
This resource from the Maternal and Child Health Integrated Program describes comprehensively the considerations program planners need to make when determining the roles and tasks of CHWs.
Determine What Responsibilities to Give CHWs
- Provide contraceptive methods in addition to counseling, and if so, which methods
- Provide counseling only, and referrals for provision of methods
- Conduct awareness-raising activities around family planning and its benefits
These decisions may depend on your country’s laws and policies.
For an example of CHW responsibilities, see the terms of reference developed for NURHI social mobilizers.
Train the CHWs
The Training Resource Package for Family Planning, a comprehensive website supported by the World Health Organization (WHO), the United Nations Population Fund (UNFPA), and the United States Agency for International Development (USAID), offers curriculum components and tools for trainers to design, implement, and evaluate family planning and reproductive health training workshops. All materials can be downloaded for free, and you may adapt or translate them for your own work.
K4Health Toolkits are practical collections of trusted global health resources, chosen by experts and arranged for easy use. The Contraceptive Methods collection, specifically, includes toolkits on most methods, including pills, condoms, injectables, implants, the IUD, permanent methods, and more, with method-specific materials for training, program management, service delivery, and health communication. The Toolkits include links to resources in multiple languages and country-specific information when available.
The Global Health eLearning Center, supported by USAID, provides many self-paced Internet-based courses that are easily accessible to the entire international health community. Some courses are in French. We recommend starting with the courses under the Family Planning Methods and Family Planning Programming topics.
To learn how Tupange developed a CHW program that followed national guidelines and also served program needs, see the East Africa Toolkit.
Most countries require CHWs to be linked to a specific health facility or post as part of the community health system structure to ensure the necessary supervisory structures, supply chain logistics and referral relationships are in place.
Your program can build on this by providing resources to strengthen the linkages, such as supervisory tools or referral cards. CHWs linked with a facility can help with the facility’s mobilization activities, to publicize the services that are available and ensure a steady stream of clients for the facility to serve.
- CHWs may be the only link that a community member has with the facility.
- Referrals of clients from CHWs can be strengthened if facility providers recognize and appreciate the work of the CHWs.
- CHWs can perform outreach to community members and mobilize them for facility-based services.
Offer Supportive Supervision
Provide CHWs with Adequate Equipment and Supplies
Consider Using CHWs Creatively for Demand Generation Activities
- In Kenya, the radio program Jongo Love provided discussion guides for all 24 episodes for listeners to continue discussing the topics raised in each episode.
- In Nigeria, the Nigerian Urban Reproductive Health Initiative (NURHI) produced a Facilitator’s Guide for discussion groups as well as a Radio Drama Discussion Guide for its program Second Chance.
CHWs can serve as mobilizers for community health service days.
- In Kenya, prior to in-reaches for long-acting and permanent methods (LAPMs), CHWs conducted publicity and promotional activities for the service day so that community members who wanted a LAPM could plan for it.
- In Senegal, on fixed free family planning service days (en français), community mobilizers helped to raise awareness of the date and location of the free family planning service and of the methods that would be available. They also provided initial counseling and information on the various methods available.
CHWs can make personal visits to homes or to workplaces.
- In Senegal, community mobilizers made house-to-house visits to sensitize people on the benefits of family planning and provide accurate information on the methods available at their nearest clinic. Using interpersonal communication skills, these mobilizers talked to women, husbands, mothers-in-law, youth and adolescents, and religious and community leaders to dispel any incorrect information and myths about family planning. They used a modified version of a provider-initiated family planning tool to identify women with unmet need for family planning and referred clients to the nearest health facility if women expressed a desire to use a modern method.
CHWs can help map urban slums to ensure these underserved areas are targeted by program activities.
- In India, CHWs used a tool to map urban slums. They then used this information to visit every home in the slums to offer information about contraceptive methods, provide short-acting methods (condoms or pills), counsel women about postpartum family planning, accompany women to health facility, and refer women to the nearest health facility or a fixed service day.
What Is the Evidence?
- The use of CHWs for family planning counseling and provision of methods increases contraceptive use. For a comprehensive yet succinct analysis of the evidence, see the High Impact Practices in Family Planning brief on CHWs.
- Allowing CHWs to provide condoms and oral contraceptives allows facility-based service providers more time to provide quality care in the facilities.
- Women in India who were exposed to CHWs were significantly more likely to be modern contraceptive method users than women who did not recall any exposure.
- In Uttar Pradesh, India, currently married fecund women with high exposure to CHWs were 1.59 times more likely to use a modern family planning method than women with no exposure to CHWs.
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When trained and provided with the necessary tools and resources, community health workers can help fill gaps in:
Community health worker roles for family planning should be limited to women.
It is important that the community health workers (CHWs) are NOT from the community they will be serving in so that they can offer a fresh perspective on family planning to the community.
The benefits of strong linkages between community health workers (CHWs) and facilities includes:
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- Work within existing Ministry of Health and community structures.
- Incorporate community family planning activities into the Ministry of Health annual work plans and budget.
- CHWs should be treated as part of the overall health system–as an extension of health facilities–rather than as a separate group.
- Men can also be CHWs. Although CHWs are often women, the Urban Health India project used male outreach workers to facilitate support groups for new fathers and young men and focused on condom use, support for exclusive breastfeeding and adoption of other postpartum family planning methods.
- Depending on your context, you may need to advocate for resources and funds to support training and creation of promotional materials for CHWs.
- If CHWs are expected to provide some contraceptive methods, they should be well-stocked and a commodity security plan should be in place.
Tools Related to This Approach
- Community Health Worker Counseling Tool for Family Planning
- Community Health Worker Job Aids Booklet
- Community Health Worker Performance Evaluation Form
- Criteria for Selecting Social Mobilizers
- Get It Together Print Materials
- Interpersonal Communication
- Kenya: Ministry of Health CHW Referral Form
- Practical Log Book for CHEW
- USAID Global Health eLearning Center course on Community-based Family Planning
- USAID Global Health eLearning Center course on Family Planning Counseling
- K4Health Toolkit on Community-based Family Planning
- Reference Guide for Program Managers and Policy Makers on Developing and Strengthening Community Health Worker Programs at Scale
- Catalogue of Community Health Systems in 18 countries (more on the way), providing information on what services are delivered at the community level and who delivers them
- Advancing Partners & Communities project website has numerous resources and success stories of community-based FP and community health systems
- FP HIPs Brief on Community Health Workers