Dashboard Nigeria: Service Delivery In-Reaches

Nigeria Toolkit: Services & Supply

In-Reaches

What is it?

In-reaches describe the provision of family planning services to clients mobilized from the community to a particular facility, usually a primary health center (PHC) on designated days of the week. The facility providers where in-reaches occur work closely with the community social mobilizers in order to synchronize mobilization days to clinic days for seamless service provision. TCI supports government to use trained and outsourced service providers in the provision of FP services across identified in-reach health facilities.

Criteria for selecting facilities for in-reaches include low uptake of family planning services, inadequate provider capacity to provide long-acting reversible contraceptive (LARC) services and a high unmet need for family planning in the community.

The approach offers the advantage of creating community awareness of available health services rendered at health facilities in a cost-effective manner. It strengthens community-facility linkages including integration of family planning into other maternal and child health services. It also fosters communication between the community and health facility staff, thus promoting community actions directed towards creating an enabling environment towards family planning. As a result, client turnout on in-reach days far exceeds the usual attendance observed on normal service delivery days.

What Are the Benefits of this Approach?

Underserved populations in greatest need for family planning services are reached with family planning information, counseling and method provision as close to their communities as possible at no additional cost.
Contraceptive use is improved particularly in areas where geographical, cultural and socio-economic barriers have limited service uptake in the past.
The capacity of more health care providers is built and strengthened to provide a broader range of methods. Specifically, providers’ knowledge and skills related to LARCs, which expands the method mix available in these geographies.
High quality contraceptive care is now integrated into other existing Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) services, such as cervical cancer screening, antenatal care, immunization services, etc.

What Are the Steps for Implementing this Approach?

The steps to implementing the approach can be viewed in three different phases.

Planning Phase

Hold a planning meeting at the state level where the LGA RH Supervisors lead the discussion on the modality of implementation of the activity and agree upon criteria for the selection of facilities, and frequency of implementation of the in-reaches among others.
Map the geographical area, noting health facilities that meet the selection criteria. This should be done in collaboration with the LGA RH Supervisors who are familiar with the geographical terrain.
Assess the sites that meet the selection criteria for cleanliness, safety, privacy and availability of family planning commodities.
Identify trained service providers from nearby health facilities within the same LGA that can be sourced, verifying availability, to support the facility-based provider and the LGA RH Supervisor in counseling and provision of services.
Make sure that family planning commodities and consumables are made available by the State to the facility prior to the facility-based in-reach.

Community Engagement & Mobilization of Clients

Provide women and children who come into contact with the facility for antenatal, immunization and post-natal clinic days with family planning information, methods and referrals.
Leverage community dialogues focusing on other program areas such as malaria, nutrition and immunization to sensitize community members on family planning and refer them to the facility for services during the in-reach.
Where indications arise, refer women who intend to take up a family planning method to other services, such as cervical cancer screening, treatment of reproductive tract infections and STI counseling, screening and treatment.
Three to five days preceding the in-reach and on the in-reach day, the LGA Health Educator and trained social mobilization teams should conduct a door-to-door campaign using local town announcers to sensitize the community, sustain awareness creation and mobilize potential clients to the chosen facility. Referral cards are issued to potential clients in the community with the aim of tracking the number of potential clients reached, number referred and the number completing referrals.
In LGAs without trained FP social mobilization teams, the social mobilizers for other program areas are oriented and utilized to disseminate family planning information to potential clients in the communities with referrals to the health facility for uptake of different family planning methods.

During the In-Reach

On each day of the in-reach, one of the service providers leads the group counseling sessions. Individual counseling follows with the service provider discussing all method options while guiding the clients in choosing the method best suited to their needs.
After counseling and method choice, clients are screened for pregnancy where necessary then directed to the private procedure area for service provision.
Following the procedure, service providers give clients detailed instructions on care of the insertion site if injectable was the chosen method, back-up contraception where required and schedule a follow-up visit.
Data of clients that accessed family planning services during the in-reach is collated by method and recorded in the facility FP Register and also reported separately as in-reach data to the LGA and ultimately State.
On the last day of the in-reach, the LGA FP Supervisors and facility team should meet at the end of the exercise to discuss areas of strength and weaknesses and plan for future in-reaches.

Key Learnings

Demand for family planning services can be particularly overwhelming during an in-reach; thus, substantial quantities of commodities and consumables must be made available to ensure there are no stock-outs during the in-reach.
Advocacy and demand generation efforts have the potential to increase support and community awareness, paving the way for rapid uptake of family planning at the in-reach service delivery points.
Many women who are initially hesitant are likely to take up a method after hearing a satisfied client share her experience.
In-reaches can meet the growing needs for family planning of underserved populations and poor couples of childbearing age, including the marginalized and vulnerable groups.
In-reaches provide a cost-effective, practical approach to on-the-job training and skill reinforcement of service providers avoiding the huge cost incurred with formal classroom trainings.
In-reaches can expand method choice, especially in health facilities without trained service providers to render LARCs.
Due to free FP services of all methods provided during the in-reaches, women and men were seen to respond easily to social mobilization efforts and there was an increase in number of completed referrals being recorded for the community.

Challenges to Be Aware of

The demand for services was particularly high during the in-reaches in some health facilities, overwhelming the available workforce and commodities and consumables provided.
Poor inclination and bias towards family planning in some communities still affect utilization of family planning within those communities.
Ineffective social mobilization and sensitization ahead of the in-reach affected the turnout of clients for the in-reach in some facilities.

Supporting Evidence

The chart below shows the uptake of family planning services for new acceptors before and during the in-reach in health facilities in Delta State. The uptake for the immediate 3-months before the in-reach were summed up to give the before data. This shows clear increase in the number of new acceptors in all facilities during in-reaches.

Source: PMIS, 2019

The pie chart below depicts the percent contribution of each method to the uptake of family planning services during in-reaches in Delta State. Implanon had the highest demand with 45% uptake, followed by Jadelle with 31% while Sayana press, Depo-Provera and female condom contribute the least with 0%, 1% and 2%, respectively.